Breast Cancer

What Is Breast Cancer?

Breast cancer is a malignant (cancer) tumor that starts from cells of the breast. It is found mostly in women, but men can get breast cancer, too. Here we will only talk about breast cancer in women. There is separate information about breast cancer in men available in our document, Breast Cancer in Men.

Parts of the normal breast

In order to understand breast cancer, it is helpful to have some basics about the normal structure or parts of the breasts, as shown in the picture below.

A woman's breast is made up of glands that make breast milk (called lobules), ducts (small tubes that carry milk from the lobules to the nipple), fatty and connective tissue, blood vessels, and lymph (pronounced limf) vessels. Most breast cancers begin in the cells that line the ducts (ductal cancer), some begin in the lobules (lobular cancer), and a small number start in other tissues.

The lymph system

The lymph system is important because it is one of the ways in which breast cancers can spread. This system has several parts.

Lymph nodes are small, bean-shaped collections of immune system cells (cells that are important in fighting infections) that are connected by lymphatic vessels. Lymphatic vessels are like small veins, except that they carry a clear fluid called lymph (instead of blood) away from the breast. Breast cancer cells can enter lymphatic vessels and begin to grow in lymph nodes.

Most lymph vessels of the breast lead to lymph nodes under the arm. These are called axillary nodes. If breast cancer cells reach the underarm lymph nodes and continue to grow, they cause the nodes to swell. It is important to know whether cancer cells have spread to lymph nodes because if they have, there is a higher chance that the cells have also gotten into the bloodstream and spread to other places in the body. This could affect the treatment plan.

Benign breast lumps

Most breast lumps are benign. This means they are not cancer. Benign breast tumors are abnormal growths, but they do not spread outside of the breast and they are not life threatening. But some benign breast lumps can increase a woman's risk of getting breast cancer.

Most lumps are caused by fibrocystic changes. Cysts are fluid-filled sacs. Fibrosis is the formation of scar-like tissue. These changes can cause breast swelling and pain. They often happen just before a period is about to begin. The breasts may feel lumpy, and sometimes there is a clear or slightly cloudy nipple discharge. For more detail, please see our document, Non-cancerous Breast Conditions.

Breast cancer terms

It can be hard to understand some of the words your health care team uses to talk about breast cancer. Here are the key words used to describe breast cancer:

Carcinoma: This is a term used to describe a cancer that begins in the lining layer of organs such as the breast. Nearly all breast cancers are carcinomas (either ductal carcinomas or lobular carcinomas).

Adenocarcinoma: An adenocarcinoma is a type of cancer that starts in glandular tissue (tissue that makes and secretes a substance). The ducts and lobules of the breast are glandular tissue (they make breast milk), so cancers starting in these areas are sometimes called adenocarcinomas.

Carcinoma in situ: This term is used for the early stage of cancer, when it is still only in the layer of cells where it began. In breast cancer, in situ means that the cancer cells are only in the ducts (ductal carcinoma in situ) or lobules (lobular carcinoma in situ). They have not spread into deeper tissues in the breast or to other organs in the body. They are sometimes referred to as non-invasive breast cancers.

Invasive (infiltrating) carcinoma: An invasive cancer is one that has already grown beyond the layer of cells where it started (unlike carcinoma in situ). Most breast cancers are invasive carcinomas -- either invasive ductal carcinoma or invasive lobular carcinoma.

Sarcoma: Sarcomas are cancers that start from connective tissues such as muscle tissue, fat tissue or blood vessels. Sarcomas of the breast are rare.

Types of breast cancers

There are many types of breast cancer, though some of them are very rare. Sometimes a breast tumor can be a mix of these types or a mixture of invasive and in situ cancer.

Ductal carcinoma in situ (DCIS): This is the most common type of non-invasive breast cancer. DCIS means that the cancer is only in the ducts. It has not spread through the walls of the ducts into the tissue of the breast. Nearly all women with cancer at this stage can be cured. Often the best way to find DCIS early is with a mammogram.

Lobular carcinoma in situ (LCIS): This condition begins in the milk-making glands but does not go through the wall of the lobules. Although not a true cancer, having LCIS increases a woman's risk of getting cancer later. For this reason, it's important that women with LCIS make sure they have regular mammograms.

Invasive (infiltrating) ductal carcinoma (IDC): This is the most common breast cancer. It starts in a milk passage or duct, breaks through the wall of the duct, and invades the tissue of the breast. From there it may be able to spread to other parts of the body. It accounts for about 8 out of 10 invasive breast cancers.

Invasive (infiltrating) lobular carcinoma (ILC): This cancer starts in the milk glands or lobules. It can spread to other parts of the body. About 1 out of 10 invasive breast cancers are of this type.

Inflammatory breast cancer (IBC): This uncommon type of invasive breast cancer accounts for about 1% to 3% of all breast cancers. Usually there is no single lump or tumor. Instead, IBC makes the skin of the breast look red and feel warm. It also gives the skin a thick, pitted appearance that looks a lot like an orange peel. The affected breast may become larger or firmer, tender, or itchy.

In its early stages, inflammatory breast cancer is often mistaken for infection. Because there is no defined lump, it may not show up on a mammogram, which may make it even harder to catch it early. It usually has a higher chance of spreading and a worse outlook than invasive ductal or lobular cancer. For more information, see our document, Inflammatory Breast Cancer.

There are also many other less common types of breast cancer. You can get information about these through our toll-free number or on our Web site.

What Causes Breast Cancer?

Certain changes in DNA can cause normal breast cells to become cancerous. DNA is the chemical in each of our cells that makes up our genes -- the instructions for how our cells work. Some inherited DNA changes can increase the risk for developing cancer and are responsible for the cancers that run in some families. But most breast cancer DNA changes happen in single breast cells during a woman's life rather than having been inherited. These are called acquired changes, and most breast cancers have several of these acquired gene mutations. But so far, the causes of most acquired mutations that could lead to breast cancer remain unknown.

While we do not yet know exactly what causes breast cancer, we do know that certain risk factors are linked to the disease. A risk factor is anything that affects a person's chance of getting a disease such as cancer. Different cancers have different risk factors. Some risk factors, such as smoking, drinking, and diet are linked to things a person does. Others, like a person's age, race, or family history, can't be changed. But risk factors don't tell us everything. Having a risk factor, or even several, doesn't mean that a person will get the disease. Some women who have one or more risk factors never get breast cancer. And most women who do get breast cancer don't have any risk factors. While all women are at risk for breast cancer, the factors listed below can increase a woman's chances of having the disease.

Although many risk factors may increase your chance of developing breast cancer, it is not yet known exactly how some of these risk factors cause cells to become cancerous. Hormones seem to play a role in many cases of breast cancer, but just how this happens is not fully understood.

Risk factors you cannot change

Gender: Simply being a woman is the main risk for breast cancer. While men also get the disease, it is about 100 times more common in women than in men.

Age: The chance of getting breast cancer goes up as a woman gets older. About 2 out of 3 women with invasive breast cancer are age 55 or older when the cancer is found.

Genetic risk factors: About 5% to 10% of breast cancers are thought to be linked to inherited changes (mutations) in certain genes. The most common gene changes are those of the BRCA1 and BRCA2 genes. Women with these gene changes have up to an 80% chance of getting breast cancer during their lifetimes. Other gene changes may raise breast cancer risk as well.

Family history: Breast cancer risk is higher among women whose close blood relatives have this disease. The relatives can be from either the mother's or father's side of the family. Having a mother, sister, or daughter with breast cancer about doubles a woman's risk. (It's important to note that 70% to 80% of women who get breast cancer do not have a family history of this disease.)

Personal history of breast cancer: A woman with cancer in one breast has a greater chance of getting a new cancer in the other breast or in another part of the same breast. This is different from a return of the first cancer (which is called recurrence).

Race: White women are slightly more likely to get breast cancer than are African-American women. But African American women are more likely to die of this cancer. At least part of the reason seems to be because African-American women have faster growing tumors. Asian, Hispanic, and American Indian women have a lower risk of getting breast cancer.

Dense breast tissue: Dense breast tissue means there is more glandular tissue and less fatty tissue. Women with denser breast tissue have a higher risk of breast cancer. Dense breast tissue can also make it harder for doctors to spot problems on mammograms.

Menstrual periods: Women who began having periods early (before age 12) or who went through the change of life (menopause) after the age of 55 have a slightly increased risk of breast cancer. They have had more menstrual periods and as a result have been exposed to more of the hormones estrogen and progesterone.

Earlier breast radiation: Women who have had radiation treatment to the chest area (as treatment for another cancer) earlier in life have a greatly increased risk of breast cancer.

Treatment with DES: In the past, some pregnant women were given the drug DES (diethylstilbestrol) because it was thought to lower their chances of losing the baby (miscarriage). Recent studies have shown that these women (and their daughters who were exposed to DES while in the womb), have a slightly increased risk of getting breast cancer. For more information on DES see our document, DES Exposure: Questions and Answers.

Breast cancer risk and lifestyle choices

Not having children or having them later in life: Women who have had not had children, or who had their first child after age 30, have a slightly higher risk of breast cancer. Being pregnant more than once and at an early age reduces breast cancer risk. Pregnancy reduces a woman's total number of lifetime menstrual cycles, which may be the reason for this effect.

Recent use of birth control pills: Studies have found that women who are using birth control pills have a slightly greater risk of breast cancer than women who have never used them. Women who stopped using the pill more than 10 years ago do not seem to have any increased risk. It's a good idea to talk to your doctor about the risks and benefits of birth control pills.

Postmenopausal hormone therapy (PHT): Postmenopausal hormone therapy (also known as hormone replacement therapy or HRT), has been used for many years to help relieve symptoms of menopause and to help prevent thinning of the bones (osteoporosis). There are 2 main types of PHT. For women who still have a womb (uterus), doctors generally prescribe estrogen and progesterone (known as combined PHT). Estrogen alone can increase the risk of cancer of the uterus, so progesterone is added to help prevent this. For women who no longer have a uterus (those who've had a hysterectomy), estrogen alone can be prescribed. This is commonly known as estrogen replacement therapy (ERT).

Combined PHT: It has become clear that long-term use (several years or more) of combined PHT increases the risk of breast cancer and may increase the chances of dying of breast cancer. The breast cancer may also be found at a more advanced stage, perhaps because PHT seems to reduce the effectiveness of mammograms. Five years after stopping PHT, the breast cancer risk seems to drop back to normal.

ERT: The use of estrogen alone does not seem to increase the risk of developing breast cancer much, if at all. But when used long-term (for more than 10 years), some studies have found that ERT increases the risk of ovarian and breast cancer.

At this time, there are few strong reasons to use PHT, other than for short-term relief of menopausal symptoms. Because there are other factors to think about, you should talk with your doctor about the pros and cons of using PHT. If a woman and her doctor decide to try PHT for symptoms of menopause, it is usually best to use it at the lowest dose that works for her and for as short a time as possible.

Not breast-feeding: Some studies have shown that breast-feeding slightly lowers breast cancer risk, especially if the breast-feeding lasts 1½ to 2 years. This could be because breast-feeding lowers a woman's total number of menstrual periods, as does pregnancy

Alcohol: Use of alcohol is clearly linked to an increased risk of getting breast cancer. Women who have one drink a day have a very small increased risk. Those who have 2 to 5 drinks daily have about 1½ times the risk of women who drink no alcohol. The American Cancer Society suggests limiting the amount you drink to one drink a day.

Being overweight or obese: Being overweight or obese is linked to a higher risk of breast cancer, especially for women after change of life and if the weight gain took place during adulthood. Also, the risk seems to be higher if the extra fat is in the waist area. But the link between weight and breast cancer risk is complex, and studies of fat in the diet as it relates to breast cancer risk have often given conflicting results. The American Cancer Society recommends you maintain a healthy weight throughout your life and avoid gaining too much weight.

Lack of exercise: Studies show that exercise reduces breast cancer risk. The only question is how much exercise is needed. One study found that as little as 1 hour and 15 minutes to 2½ hours of brisk walking per week reduced the risk by 18%. Walking 10 hours a week reduced the risk a little more. The American Cancer Society suggests that you exercise for 45 to 60 minutes 5 or more days a week.

Uncertain risk factors

High fat diets: Studies of fat in the diet have not clearly shown that this is a breast cancer risk factor. Most studies found that breast cancer is less common in countries where the typical diet is low in fat. On the other hand, many studies of women in the United States have not found breast cancer risk to be linked to how much fat they ate. Researchers are still not sure how to explain this difference. More research is needed to better understand the effect of the types of fat eaten and body weight on breast cancer risk.

The American Cancer Society recommends eating a healthy diet that includes 5 or more servings of vegetables and fruits each day, choosing whole grains over processed (refined) grains, and limiting the amount of processed and red meats.

Antiperspirants and bras: Internet e-mail rumors have suggested that underarm antiperspirants can cause breast cancer. There is very little evidence to support this idea. Also, there is no evidence to support the idea that under wire bras cause breast cancer.

Abortions: Several studies show that induced abortions do not increase the risk of breast cancer. Also, there is no evidence to show a direct link between miscarriages and breast cancer. For more detailed information, see our document, Can Having an Abortion Cause or Contribute to Breast Cancer?

Breast implants: Silicone breast implants can cause scar tissue to form in the breast. But several studies have found that this does not increase breast cancer risk. If you have breast implants, you might need special x-ray pictures during mammograms.

Pollution: A lot of research is being done to learn how the environment might affect breast cancer risk. At this time, research does not show a clear link between breast cancer risk and environmental pollutants such as pesticides and PCBs.

Tobacco Smoke: Most studies have found no link between active cigarette smoking and breast cancer. An issue that continues to be a focus of research is whether secondhand smoke (smoke from another person's cigarette) may increase the risk of breast cancer. But the evidence about secondhand smoke and breast cancer risk in human studies is not clear. In any case, a possible link to breast cancer is yet another reason to avoid being around secondhand smoke.

Night Work: A few studies have suggested that women who work at night (nurses on the night shift, for example) have a higher risk of breast cancer. This is a fairly recent finding, and more studies are being done to look at this issue.

How Is Breast Cancer Found?

How Is Breast Cancer Found?

The term screening refers to tests and exams used to find a disease like cancer in people who do not have any symptoms. The earlier breast cancer is found, the better the chances that treatment will work. The goal is to find cancers before they start to cause symptoms. The size of a breast cancer and how far it has spread are the most important factors in predicting the outlook for the patient. Most doctors feel that early detection tests for breast cancer save many thousands of lives each year. Following the guidelines given here improves the chances that breast cancer can be found at an early stage and treated with success.

ACS recommendations for early breast cancer detection

The ACS recommends the following guidelines for finding breast cancer early in women without symptoms:

Mammogram: Women age 40 and older should have a screening mammogram every year and should continue to do so for as long as they are in good health. While mammograms can miss some cancers, they are still a very good way to find breast cancer.

Clinical breast exam: Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a regular exam by a health expert, at least every 3 years. After age 40, women should have a breast exam by a health expert every year. It might be a good idea to have the CBE shortly before the mammogram. You can use the exam to learn what your own breasts feel like.

Breast self-exam (BSE): BSE is an option for women starting in their 20s. Women should be told about the benefits and limitations of BSE. Women should report any changes in how their breasts look or feel to their health professional right away.

Research has shown that BSE plays a small role in finding breast cancer compared with finding a breast lump by chance or simply being aware of what is normal for each woman. If you decide to do BSE, you should have your doctor or nurse check your method to make sure you are doing it right. If you do BSE on a regular basis, you get to know how your breasts normally look and feel. Then you can more easily notice changes. But it's OK not to do BSE or not to do it on a fixed schedule.

The goal, with or without BSE, is to see your doctor right away if you notice any of these changes: a lump or swelling, skin irritation or dimpling, nipple pain or the nipple turning inward, redness or scaliness of the nipple or breast skin, or a discharge other than breast milk. But remember that most of the time these breast changes are not cancer.

Women at high risk: Women with a higher risk of breast cancer should talk with their doctor about the best approach for them. This might mean starting mammograms when they are younger, having extra screening tests, or having more frequent exams.

Mammograms

A mammogram is an x-ray of the breast. This test is used to look for breast disease in women who do not seem to have breast problems. It can also be used when women have symptoms such as a lump, skin change, or nipple discharge.

During a mammogram, the breast is pressed between 2 plates to flatten and spread the tissue. The pressure lasts only for a few seconds. Although this may cause some pain for a moment, it is needed to get a good picture. Very low levels of radiation are used. While many people are worried about exposure to x-rays, the low level of radiation used for mammograms does not increase the risk of breast cancer. To put dose into perspective, if a woman with breast cancer is treated with radiation, she will get around 5,000 rads (a term used to measure radiation dose). If she had a mammograms every year from age 40 to age 90, she will have had 20 to 40 rads total.

For the mammogram, you undress above the waist. You will have a wrap to cover yourself. A technologist (most often a woman) will position your breast correctly for the test. The pressure lasts only a few seconds while the picture is taken. The whole procedure takes about 20 minutes. You should get your results within 30 days or even sooner.

About 1 in 10 women who get a mammogram will need more pictures taken. But most of these women do not have breast cancer, so don't be alarmed if this happens to you. Only 2 to 4 of every 1,000 mammograms leads to a diagnosis of cancer.

Women with a higher risk of breast cancer should talk with their doctor about the best approach for them. They may benefit from starting mammograms when they are younger, having them more often, or having other tests along with them. If you are at higher risk, your doctor might recommend an ultrasound or MRI (magnetic resonance imaging) be done along with your mammograms.

Medicare, Medicaid, and most private health plans cover all or part of the cost of this test. Call us at 1-800-ACS-2345 (1-800-227-2345) for information about facilities in your area. Breast cancer testing is available to women without health insurance for free or at very little cost through a special program called the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Your state's Department of Health will have information about this program. There is also a new program to help pay for breast cancer treatment for women in need. To learn more about these programs, you can contact the Centers for Disease Control and Prevention at 1-800-CDC INFO (1-800-232-4636) or on the Internet at www.cdc.gov/cancer/nbccedp.

Clinical breast exam

A clinical breast exam (CBE) is an exam of your breasts by a health expert such as a doctor, nurse practitioner, nurse, or physician assistant. For this exam, you undress from the waist up. The examiner will first look at your breasts for changes in size or shape. Then, using the pads of the fingers, she or he will gently feel your breasts for lumps. The area under both arms will also be checked. This is a good time to learn how to do breast self-exam if you don't already know how.

Breast awareness and breast self-exam

Women should be aware of how their breasts normally look and feel and report any changes to their doctor right away. Finding a change does not mean that you have cancer.

By being aware of how your own breasts look and feel, you are likely to notice any changes that might take place. You can also choose to use a step-by-step approach to checking your breasts on a set schedule. The best time to do breast self-examination (BSE) is when your breasts are not tender or swollen. If you find any changes, see your doctor right away.

Women with breast implants can do BSE. It may help to have the surgeon help identify the edges of the implant so that you know what you are feeling. It may be that the implants push out the breast tissue and actually make it easier to examine.

It's OK for women not to do BSE or to do it once in a while. We have detailed information on how to do BSE for women who want to do it. You can find it on our Web site or you can call and ask for it.

MRI (magnetic resonance imaging)

For certain women at high risk for breast cancer, screening MRI is recommended along with a yearly mammogram. It is not generally recommended as a screening tool by itself as it may miss some cancers that mammograms would find. MRI also costs more than mammograms. Most major insurance companies will likely pay for a screening MRI if a woman can be shown to be at high risk, but it's not yet clear if all companies will do so. More details about MRI can be found below.

Symptoms of breast cancer

The widespread use of screening mammograms has increased the number of breast cancers found before they cause any symptoms, but some are still missed.

The most common sign of breast cancer is a new lump or mass. A lump that is painless, hard, and has uneven edges is more likely to be cancer. But some cancers are tender, soft, and rounded. So it's important to have anything unusual checked by a doctor.

Other signs of breast cancer include the following:

• swelling of all or part of the breast
• skin irritation or dimpling
• breast pain
• nipple pain or the nipple turning inward
• redness, scaliness, or thickening of the nipple or breast skin
• a nipple discharge other than breast milk
• a lump in the underarm area

How Is Breast Cancer Treated?

This information represents the views of the doctors and nurses serving on the American Cancer Society's Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.

The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.

Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don't hesitate to ask him or her questions about your treatment options.

General types of treatment

Treatments can be put into broad groups based on how they work and when they are used.

Local vs. systemic treatment

The purpose of local treatment is to treat a tumor without affecting the rest of the body. Surgery and radiation are examples of local treatment.

Systemic treatment is given into the bloodstream or by mouth to go throughout the body and reach cancer cells that may have spread beyond the breast. Chemotherapy, hormone therapy, and immunotherapy are systemic treatments.

Adjuvant and neoadjuvant therapy

When people who seem to have no cancer left after surgery are given more treatment it is referred to as adjuvant therapy. Doctors now think that cancer cells can break away from the main tumor and begin to spread through the bloodstream in the early stages of the disease. It's very hard to tell if this has happened. But if it has, the cancer cells can start new tumors in other organs or the bones. The goal of adjuvant therapy is to kill these hidden cells. But not every patient needs adjuvant therapy.

Some people are given systemic treatment (most likely chemotherapy) before surgery to shrink a tumor. This is called neoadjuvant therapy.

Surgery for breast cancer

Most women with breast cancer will have some type of surgery to treat the main breast tumor. The purpose of surgery is to remove as much of the cancer as possible. Surgery can also be done to find out whether the cancer has spread to the lymph nodes under the arm (axillary dissection), to restore the breast's appearance after a mastectomy, or to relieve symptoms of advanced cancer. Below is a list of some of the most common types of breast cancer surgery.

Breast-conserving surgery

In these types of surgery, only a part of the breast is removed. How much is removed depends on the size and place of the tumor and other factors.

Lumpectomy: This surgery removes only the breast lump and some normal tissue around it. Radiation treatment is usually given after this type of surgery. If chemotherapy is also going to be used, the radiation may be put off until the chemo is finished. If there is cancer at the edge of the piece of tissue that was removed, the surgeon may need to go back and take out more tissue.

Partial (segmental) mastectomy or quadrantectomy: This surgery removes more of the breast tissue than in a lumpectomy. It is usually followed by radiation therapy. Again, this may be delayed if chemotherapy is also going to be given.

Side effects of these operations can include pain, short-term swelling, tenderness, and hardness due to scar tissue that forms in the surgical site.

Mastectomy

Mastectomy involves removing of all of the breast tissue, sometimes along with other nearby tissues.

Simple or total mastectomy: In this surgery the entire breast is removed, but not the lymph nodes under the arm or the muscle tissue beneath the breast. Sometimes both breasts are removed, especially when mastectomy is done to try to prevent cancer. If a hospital stay is needed, most women can go home the next day.

Modified radical mastectomy: This operation involves removing the entire breast and some of the lymph nodes under the arm. This is the most common surgery for women with breast cancer who are having the whole breast removed.

Radical mastectomy: This is a major operation where the surgeon removes the entire breast, underarm (axillary) lymph nodes, and the chest wall muscles under the breast. This surgery was once very common, but it is rarely done now. This is because modified radical mastectomy has proven to work just as well with less disfigurement and fewer side effects.

Possible side effects: Aside from pain after the surgery and the change in the shape of the breast(s), the possible side effects of mastectomy and lumpectomy include wound infection, build-up of blood in the wound, and build-up of clear fluid in the wound. If axillary lymph nodes are also removed, other side effects are possible, such as swelling of the arm (lymphedema).

Choosing between lumpectomy and mastectomy

Many women with early stage cancers can choose between breast-conserving surgery and mastectomy. One advantage of lumpectomy is that it saves the way the breast looks. A downside is the need for many weeks of radiation after surgery. But some women who have a mastectomy will still need radiation.

When choosing between a lumpectomy and mastectomy, be sure to get all the facts. You may have an initial gut preference for mastectomy as a way to "take it all out as quickly as possible." Women tend to prefer mastectomy more often than their surgeons do because of this feeling. But the fact is that for most women with stage I or II breast cancer, lumpectomy or partial mastectomy (along with radiation) is as good as mastectomy. There is no difference in the survival rates of women treated with these 2 methods. Other factors, though, can affect which type of surgery is best for you. And lumpectomy is not an option for all women with breast cancer. Your doctor can tell you if there are reasons why a lumpectomy is not right for you.

Other breast cancer surgeries

Axillary lymph node dissection: This operation is done to find out if the breast cancer has spread to lymph nodes under the arm. Some nodes are removed and looked at under a microscope. Whether or not cancer cells are found in the lymph nodes under the arm is an important factor in choosing adjuvant therapy. It was once believed that removing as many lymph nodes as possible would reduce the risk of spread to other parts of the body and improve the chance of curing the cancer. It is now known that breast cancer cells that have spread beyond the breast and axillary lymph nodes are best treated by systemic therapy. Axillary dissection is used as a test to help guide other breast cancer treatment decisions.

A possible side effect of removing these lymph nodes is swelling of the arm, called lymphedema. This happens in 1 out of 4 women who have had these nodes removed. Women who have swelling, tightness, or pain in the arm after lymph node surgery should be sure to tell their doctor right away. Often there are measures to prevent or reduce the effects of the swelling. You can get more information about lymphedema by calling our toll-free number or looking on our Web site.

Sentinel lymph node biopsy: A sentinel lymph node biopsy is a way to look at the lymph nodes without having to remove all of them. For this test, a radioactive substance and/or a dye are injected near the tumor. This is carried by the lymph system to the first (sentinel) node(s) to get lymph from the tumor. This lymph node (or nodes) is the one most likely to contain cancer cells if the cancer has spread. These nodes (often 2 or 3) are then looked at by the pathologist. If the sentinel nodes contain cancer, more lymph nodes are removed. If they are free of cancer, further lymph node surgery might not be needed. This type of biopsy calls for a great deal of skill, so it is best to have it done by a team who has experience with it.

Reconstructive or breast implant surgery: These operations are not meant to treat the cancer. They are done to restore the way the breast looks after mastectomy. If you are having a mastectomy and are thinking about having breast reconstruction, you should talk to a plastic surgeon before your operation. There are several choices about when the surgery can be done and exactly what type it will be.

You can get more detailed information about each of these types of surgery and their possible side effects in our document, Breast Reconstruction after Mastectomy. You may also find it helpful to talk with a woman who has had the type of reconstruction you are thinking about. Our Reach to Recovery volunteers can help you with this. Call us if you would like to speak to one of these volunteers.

What to expect with surgery

For many women, the thought of surgery can be frightening. But a better understanding of what to expect before, during, and after the operation may help ease your fears.

Before surgery: A few days after your biopsy you will know whether or not you have cancer, but the extent of the disease will not be known until after surgery. You will most likely meet with your surgeon a few days before the operation to talk about what will happen. You will be asked to sign a consent form giving the doctor permission to do the surgery. This is a good time to ask any questions you might have.

You may be asked to donate blood ahead of time in case you need it during the surgery. Your doctor will also ask you about medicines, vitamins, or supplements you are taking. You might need to stop taking some of them a week or 2 before surgery.

Surgery: For your surgery, you may be offered the choice of an outpatient procedure or you may be admitted to the hospital. The type of anesthesia you will have depends on the kind of surgery being done and your own situation. General anesthesia is usually given whenever the surgery involves a mastectomy or an axillary node dissection, and is most often used during breast-conserving surgery, too. You will have an IV line put in (usually into a vein in your arm). It will be used to give medicines that may be needed during the surgery. You will be hooked up to an electrocardiogram (EKG) machine and have a blood pressure cuff on your arm, so your heart rhythm and blood pressure can be checked during the surgery.

How long the surgery will take and how long you will be in the hospital also depends on the type of surgery being done. For example, a mastectomy with lymph node removal will take from 2 to 3 hours. After your surgery, you will be taken to the recovery room, where you will stay until you are awake and your vital signs (blood pressure, pulse, and breathing) are stable.

After surgery: How long you stay in the hospital depends on the type of surgery you had, your overall state of health, whether you have any other medical problems, how well you do during the surgery, and how you feel after the surgery. You and your doctor should decide how long you need to stay in the hospital -- not your insurance company. Still, it is important to check your insurance coverage before surgery.

As a rule, women having a mastectomy stay in the hospital for 1 or 2 nights and then go home. But some women may be placed in a 23-hour, short-stay unit before going home. In this case, a home care nurse may visit you after you leave the hospital.

Less involved operations such as lumpectomy and sentinel lymph node biopsy are usually done on an outpatient basis and do not require an overnight stay in the hospital.

After surgery you will have a bandage over the surgery site that may wrap snugly around your chest. You may have one or more tubes (drains) from the breast or underarm area to remove fluid that collects during the healing process. Most drains stay in place for 1 or 2 weeks. Once the flow has gone down to about 1 ounce a day, the drain will be removed.

Most doctors will want you to start moving your arm soon after surgery so that it won't get stiff. Many women who have a lumpectomy or mastectomy are surprised by how little pain they have in the breast area. But they are less happy with the strange feelings (numbness, pinching/pulling) in the underarm area.

Talk with your doctor about what you should do after the surgery to care for yourself. You should get written instructions that will tell you about the following:

• how to take care of the wound and dressing
• how to take care of the drains
• how to know if you have an infection
• when to call the doctor or nurse
• when to begin using the arm and how to do arm exercises to prevent stiffness
• when to start wearing a bra again
• when and how to wear a breast form (sometimes called a prosthesis)
• what to eat and what not to eat
• what medicines to take (including pain medicines and maybe antibiotics)
• what activities you should or should not do
• what feelings you might have about how you look
• when to see your doctor for a follow-up appointment
• how to contact a Reach to Recovery volunteer -- These specially trained women can provide information, comfort, and support.

Most patients see their doctor about 7 to 14 days after the surgery. Your doctor should explain the results of your pathology report and talk to you about whether you will need further treatment.

Radiation therapy

Radiation therapy is treatment with high-energy rays (such as x-rays) to kill or shrink cancer cells. This treatment may be used to kill any cancer cells that remain in the breast, chest wall, or underarm area after breast-conserving surgery. There are 2 main ways in which radiation therapy can be given.

External beam radiation

Most often, external beam radiation is used for treating breast cancer. It is much like getting a regular x-ray but for a longer period of time. Radiation therapy may be used to destroy cancer cells remaining in the breast, chest wall, or underarm area after surgery or, less often, to reduce the size of a tumor before surgery.

Treatment is usually given 5 days a week in an outpatient center over a period of about 6 or 7 weeks, beginning about a month after surgery. Each treatment lasts a few minutes. The treatment itself is painless. Ink marks or small tattoos may be put on your skin. These will be used as a guide to focus the radiation on the right area. You may want to talk to your health care team to find out if these marks will be permanent. If it is used along with chemotherapy, radiation is usually given after chemotherapy is finished.

Newer techniques now being studied involve giving radiation over a much shorter period of time and to only the part of the breast with the cancer. This is called accelerated radiation. In one approach, larger doses of radiation are given each day, but the course of radiation is shortened to only 5 days. In another approach, one large dose of radiation is given in the operating room right after lumpectomy (before the breast incision is closed). Most doctors still consider accelerated radiation to be experimental at this time.

The main side effects of radiation therapy are swelling and heaviness in the breast, sunburn-like changes in the skin over the treated area, and fatigue. These changes to the breast tissue and skin usually go away in 6 to 12 months. In some women, the breast becomes smaller and firmer after radiation therapy. Radiation therapy of axillary lymph nodes also can cause long-term arm swelling called lymphedema. You can get more information on lymphedema in the "Moving on after treatment" section.

Brachytherapy

Another way to give radiation is to place radioactive seeds (pellets) into the breast tissue next to the cancer. It may be given along with external beam radiation to add an extra “boost” of radiation to the tumor. It is also being studied as the only source of radiation. So far the results have been good, but more study is needed before brachytherapy alone can be used as standard treatment.

One method of brachytherapy being used is called Mammosite^®. It consists of a balloon attached to a thin tube. The balloon is placed into the lumpectomy space and filled with salt water. Radioactivity is added through the tube. The radioactive material is added and removed twice a day (on an outpatient basis) for 5 days. Then the balloon is deflated and removed.

Chemotherapy

Chemotherapy (most often called just "chemo") is the use of cancer-killing drugs. These drugs can be injected into a vein, given as a shot, or taken as a pill or liquid. They enter the bloodstream and go throughout the body, making this treatment useful for cancers that have spread to distant organs. While these drugs kill cancer cells, they also damage some normal cells, which can lead to side effects.

When is chemotherapy used?

There are many cases where chemo may be used.

Adjuvant chemotherapy: Treatment given to patients after surgery who do not seem to have any spread of cancer is called adjuvant therapy. When used this way after breast-conserving surgery or mastectomy, chemo reduces the risk of the breast cancer coming back.

Even in the early stages of the disease, cancer cells can break away from the first breast tumor and spread through the bloodstream. These cells don't cause symptoms, they don't show up on an x-ray, and they can't be felt during a physical exam. But if they are allowed to grow, they can form new tumors in other places in the body. Adjuvant chemo can be given to find and kill these cells.

Neoadjuvant chemotherapy: Chemo given before surgery is called neoadjuvant therapy. The major benefit of this approach is that it can shrink large cancers so that they are small enough to be removed by lumpectomy instead of mastectomy. Another possible advantage is that doctors can see how the cancer responds to the chemo. If the tumor does not shrink, then different drugs may be needed. So far, it is not clear that neoadjuvant chemo improves survival, but it seems to be at least as effective as adjuvant therapy after surgery.

Chemo for advanced breast cancer: Chemo can also be used as the main treatment for women whose cancer has already spread outside the breast and underarm area at the time it is found, or if it spreads after the first treatments.

How is chemo given?

In most cases chemo works best if more than one drug is used. Doctors give chemo in cycles, with each period of treatment followed by a rest period. The time between treatments is most often 2 or 3 weeks and varies according to the drug or combination of drugs being used. The total course of treatment usually lasts for 3 to 6 months. Treatment may be longer for advanced breast cancer.

Possible side effects

The side effects of chemo depend on the type of drugs used, the amount given, and the length of treatment. You could experience some of these short-term side effects:

• hair loss
• mouth sores
• loss of appetite
• nausea and vomiting
• a higher risk of infection (from low white blood cell counts)
• changes in menstrual cycle (this could be permanent)
• easy bruising or bleeding (from low blood platelet counts)
• being very tired (called fatigue, often caused by low red blood cell counts or other reasons)

Most of these side effects go away when treatment is over. For example, your hair will grow back and your blood counts will return to normal. If you have any problems with side effects, be sure to tell your doctor or nurse because there are often ways to help.

Menstrual changes: For younger women, changes in menstrual periods are another possible side effect of chemo. Permanent side effects can include early change of life (menopause) and not being able to become pregnant (infertility). But being on chemo does not always prevent pregnancy and getting pregnant while on chemo can lead to birth defects. If you are having sex, you should discuss birth control with your cancer doctor.

Neuropathy: Several drugs used to treat breast cancer can damage nerves. This can sometimes lead to symptoms (mainly in the hands and feet) such as pain, burning or tingling sensations, sensitivity to cold or heat, or weakness. In most cases this goes away once treatment is stopped, but it may be long-lasting in some women. You can learn more about this in our document Peripheral Neuropathy Caused by Chemotherapy.

Heart damage: Some of the drugs may cause heart damage if used for a long time or in high doses. Doctors are careful to control the doses of these drugs and watch for signs of problems.

Chemo brain: Many women who have had chemo notice a change in concentration and memory. This is often called “chemo brain.” It may last a long time. Still, most women function well after chemo. In studies that have found chemo brain to be a side effect of treatment, the symptoms most often go away in a few years. For more information, see our document, Chemo Brain.

Increased risk of leukemia: Very rarely, years after treatment for breast cancer, certain chemo drugs may cause another cancer called acute myeloid leukemia (AML). But for most women the benefit of treating the breast cancer far outweighs the risk of this rare event.

Feeling unwell or tired: Many women do not feel as healthy after having chemo as they did before. Fatigue can be another long-lasting problem for women who have had chemo. This may last for many years, but it can be helped. Talk to your doctor if fatigue is a problem for you. You can also get more information in our document Fatigue in People with Cancer.

Hormone therapy

Hormone therapy is another form of systemic therapy. It is most often used to help reduce the risk of the cancer coming back after surgery, though it may also be used for more advanced breast cancers.

The female hormone estrogen promotes the growth of breast cancer cells in some women (those who have ER-positive cancers). For these women, things are done to block the effect of estrogen or lower its levels in order to treat breast cancer.

Drugs used to change hormone levels

Tamoxifen and toremifene (Fareston^®): Drugs like tamoxifen can be given to counter the effects of estrogen. Tamoxifen is taken in pill or liquid form, usually every day for up to 5 years after surgery, to reduce the risk the cancer will come back. This drug helps women with early breast cancer if their cancer has estrogen receptors (is ER-positive). It is also used to treat breast cancer that has spread and to reduce the risk of breast cancer in women who are at high risk.

This drug does have known side effects. The most common side effects include fatigue, hot flashes, vaginal discharge, and mood swings. Some studies have shown an increase of early stage cancer of the lining of the uterus among women taking tamoxifen. But this cancer is usually found at a very early stage and is almost always cured by surgery. If you are taking tamoxifen and have any unusual vaginal bleeding you should tell your doctor right away. Blood clots are another possible side effect of tamoxifen. Still, for most women with breast cancer, the benefits of tamoxifen far outweigh the risks.

Fulvestrant: Fulvestrant (Faslodex^®) is a drug that acts by damaging the estrogen receptor instead of blocking it. It often works even if the breast cancer is no longer responding to tamoxifen. It is given by injection once a month. Hot flashes, mild nausea, and fatigue are the major side effects. It is only given to women who are already in menopause. Right now it is only used in post-menopausal women with advanced breast cancer that no longer responds to tamoxifen or toremifene.

Aromatase inhibitors: These are drugs that stop the body from making estrogen. They only work for women who are past menopause and whose cancers are hormone-receptor positive. These drugs may be used after, or even instead of tamoxifen to reduce the chance of the breast cancer coming back. These drugs are taken daily as pills.

They don't cause uterine cancer and very rarely cause blood clots. But they can cause bone thinning and fractures because they remove estrogens from the body. The most common side effect of these drugs is joint stiffness and/or pain like the feeling of having arthritis in many different joints at one time.

Surgery to change hormone levels

Removing the ovaries (ovarian ablation): In pre-menopausal women, the ovaries are the main source of estrogens. Removing them or shutting them down takes away almost all the estrogen and makes the woman post-menopausal. This may allow some other hormone therapies to work better. Ovarian ablation can be done permanently by taking out the ovaries in surgery. It also can be done with drugs. Both of these methods can cause a woman to have symptoms of menopause, including hot flashes, night sweats, vaginal dryness, and mood swings.

Other ways to change hormone levels

Androgens (male hormones) may be used after other hormone treatments for advanced breast cancer have been tried. They sometimes work, but they can cause women to develop male traits, like an increase in body hair and a deeper voice.

Targeted therapy

As we have learned more about the gene changes that cause cancer, researchers have been able develop newer drugs that are aimed right at these changes. These targeted drugs do not work the same as standard chemo drugs. They often have different and less severe side effects. At this time, they are most often used along with chemo.

Trastuzumab (Herceptin)

This is a monoclonal antibody -- a manmade version of a very specific immune system protein. It attaches to the growth-promoting protein called HER2/neu. HER2/neu is found in small amounts on the surface of normal breast cells and in large amounts on some breast cancer cells. Breast cancers that have too much of this protein are called HER2/neu-positive. The protein makes them grow and spread faster. Herceptin can stop this protein from causing breast cancer cell growth. It may also help the immune system to better attack the cancer.

The side effects of this drug are fairly mild. They may include fever and chills, weakness, nausea, vomiting, cough, diarrhea, and headache. These side effects are less common after the first dose. But some women may develop heart damage during treatment. For most (but not all) women, this effect has been short-term and bets better when the drug is stopped. If you are getting Herceptin, you should tell your doctor right away if you have any shortness of breath, swelling, or trouble with physical activities.

Lapatinib (Tykerb)

This is another drug that targets the HER2/neu protein. This drug is given as a pill, most often along with chemo. It is used for some women with cancer that is no longer helped by chemo and Herceptin. The most common side effects with this drug include diarrhea, nausea, vomiting, rash, and hand-foot syndrome, which may include numbness, tingling, redness, swelling, and pain in the hands and feet. Diarrhea is common and can be bad. It is very important to let your health care team know about any changes in your bowel habits as soon as they happen.

Bevacizumab (Avastin)

This is another monoclonal antibody that may be used in patients with breast cancer that has spread. It is always used along with other chemo drugs. This antibody helps to keep tumors from making new blood vessels to feed the tumor. Avastin is given by intravenous (IV) infusion. There can be some rare, though serious, side effects and high blood pressure is very common. It very important that your doctor watches your blood pressure carefully during treatment and that you let your health care team know about any changes in how you feel.

Bisphosophonates

Bisphosphonates are drugs that are used when breast cancer has spread to the bones. These drugs can strengthen bones that have been weakened by invading breast cancer cells and reduce the risk of fractures or breaks. Bisphosphonates may also help prevent bone thinning (osteoporosis) that can result from treatment with aromatase inhibitors (see above) or from early menopause caused by chemo. These drugs are given into a vein (IV).

Bisphosphonates can have side effects, including flu-like symptoms and bone pain. A rare but serious side effect from bisphosphonates is damage in the jaw bone. Doctors don't know why this happens. Some cancer doctors recommend that patients have a dental check-up and have any tooth or jaw problems treated before they start taking bisphosphonates.

High-dose chemo with bone marrow or peripheral blood stem cell transplant

In the past, it was thought that very high doses of chemo followed by a stem cell transplant might offer some women the best chance for a cure--especially those women with a high risk of the cancer coming back or with advanced cancer. But doctors have found that the women who had high-dose therapy did not live any longer than women who had standard dose chemo. And high-dose chemo with stem cell support can cause serious side effects. Research in this area is still going on. For now, experts in the field suggest that women receive this treatment only as part of a clinical trial.

Treatment of breast cancer during pregnancy

Treatment for pregnant women with breast cancer depends on how long the woman has been pregnant.

Radiation therapy during pregnancy is known to increase the risk of birth defects, so it is not recommended for pregnant women with breast cancer. For this reason, breast-conserving therapy (lumpectomy and radiation therapy) is not an option unless treatment can be delayed until it is safe to deliver the baby. A breast biopsy and even modified radical mastectomy are safe for the mother and the fetus.

For a long time it was thought that chemo was dangerous to the fetus. But some recent studies have found that using certain chemo drugs during the fourth to ninth months does not increase the risk of birth defects. The safety of chemo during the first 3 months of pregnancy has not been studied.

Hormone therapy may affect the fetus and should not be started until after the patient has given birth.

Many chemo and hormone therapy drugs can enter breast milk and could be passed on to the baby, so breast-feeding is not usually recommended if the woman is having these treatments.

For more information, see our document, Pregnancy and Breast Cancer.