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Articles » What You Need To Know About Breast Cancer: NCI
 

What You Need To Know About Breast Cancer: NCI

Article title: What You Need To Know About Breast Cancer: NCI

Conditions: Breast cancer, male breast cancer, Lobular carcinoma in situ, Ductal carcinoma in situ

Source: NCI


Introduction

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

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

Words that may be new to readers are printed in italics. Definitions of these and other terms related to breast cancer are listed in the Dictionary. For some words, a "sounds-like" spelling is also given.

Male Breast Cancer

Breast cancer affects more than 1,000 men in this country each year. Although this booklet was written mainly for women, much of the information on symptoms, diagnosis, treatment, and living with the disease applies to men as well. However, the "Detecting Breast Cancer" section does not apply to men. Experts do not recommend routine screening for men.

Research has led to progress against breast cancer -- better treatments, a lower chance of death from the disease, and improved quality of life. Through research, knowledge about breast cancer keeps increasing. Scientists are learning more about what causes breast cancer and are exploring new ways to prevent, detect, diagnose, and treat this disease.

The Cancer Information Service at 1-800-4-CANCER and other NCI resources listed under "National Cancer Institute Information Resources" can provide the latest, most accurate information on breast cancer. Publications listed in the "National Cancer Institute Booklets" section are available from the Cancer Information Service. Also, many NCI publications may be viewed or ordered on the Internet at http://www.nci.nih.gov/publications.

The Breasts

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

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


This diagram shows the breast.

Understanding the Cancer Process

Cancer is a group of many related diseases that begin in cells, the body's basic unit of life. To understand cancer, it is helpful to know what happens when normal cells become cancerous.

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

  • Benign tumors are not cancer. They can usually be removed, and in most cases, they do not come back. Cells from benign tumors do not spread to other parts of the body. Most important, benign breast tumors are not a threat to life.

  • Malignant tumors are cancer. Cells in these tumors are abnormal. They divide without control or order, and they can invade and damage nearby tissues and organs. Also, cancer cells can break away from a malignant tumor and enter the bloodstream or the lymphatic system. That is how cancer spreads from the original (primary) cancer site to form new tumors in other organs. The spread of cancer is called metastasis.

When cancer arises in breast tissue and spreads (metastasizes) outside the breast, cancer cells are often found in the lymph nodes under the arm (axillary lymph nodes). If the cancer has reached these nodes, it means that cancer cells may have spread to other parts of the body -- other lymph nodes and other organs, such as the bones, liver, or lungs. When cancer spreads from its original location to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the primary tumor. For example, if breast cancer spreads to the brain, the cancer cells in the brain are actually breast cancer cells. The disease is called metastatic breast cancer. (It is not brain cancer.) Doctors sometimes call this "distant" disease.

This booklet deals with breast cancer. For information about benign breast lumps and other benign breast changes, read NCI's booklet, Understanding Breast Changes: A Health Guide for All Women.

Breast Cancer: Who's at Risk?

The exact causes of breast cancer are not known. However, studies show that the risk of breast cancer increases as a woman gets older. This disease is very uncommon in women under the age of 35. Most breast cancers occur in women over the age of 50, and the risk is especially high for women over age 60. Also, breast cancer occurs more often in white women than African American or Asian women.

Research has shown that the following conditions increase a woman's chances of getting breast cancer:

  • Personal history of breast cancer. Women who have had breast cancer face an increased risk of getting breast cancer in their other breast.

  • Family history. A woman's risk for developing breast cancer increases if her mother, sister, or daughter had breast cancer, especially at a young age.

  • Certain breast changes. Having a diagnosis of atypical hyperplasia or lobular carcinoma in situ (LCIS) may increase a woman's risk for developing cancer.

  • Genetic alterations. Changes in certain genes (BRCA1, BRCA2, and others) increase the risk of breast cancer. In families in which many women have had the disease, gene testing can sometimes show the presence of specific genetic changes that increase the risk of breast cancer. Doctors may suggest ways to try to delay or prevent breast cancer, or to improve the detection of this disease in women who have these changes in their genes. For more information about gene testing, read the "Causes and Prevention" section under "The Promise of Cancer Research."

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

  • Estrogen. Evidence suggests that the longer a woman is exposed to estrogen (estrogen made by the body, taken as a drug, or delivered by a patch), the more likely she is to develop breast cancer. For example, the risk is somewhat increased among women who began menstruation at an early age (before age 12), experienced menopause late (after age 55), never had children, or took hormone replacement therapy for long periods of time. Each of these factors increases the amount of time a woman's body is exposed to estrogen.

    DES (diethylstilbestrol) is a synthetic form of estrogen that was used between the early 1940s and 1971. Women who took DES during pregnancy to prevent certain complications are at a slightly higher risk for breast cancer. This does not appear to be the case for their daughters who were exposed to DES before birth. However, more studies are needed as these daughters enter the age range when breast cancer is more common.

  • Late childbearing. Women who have their first child late (after about age 30) have a greater chance of developing breast cancer than women who have a child at a younger age.

  • Breast density. Breasts that have a high proportion of lobular and ductal tissue appear dense on mammograms. Breast cancers nearly always develop in lobular or ductal tissue (not fatty tissue). That's why cancer is more likely to occur in breasts that have a lot of lobular and ductal tissue (that is, dense tissue) than in breasts with a lot of fatty tissue. In addition, when breasts are dense, it is more difficult for doctors to see abnormal areas on a mammogram.

  • Radiation therapy. Women whose breasts were exposed to radiation during radiation therapy before age 30, especially those who were treated with radiation for Hodgkin's disease, are at an increased risk for developing breast cancer. Studies show that the younger a woman was when she received her treatment, the higher her risk for developing breast cancer later in life.

  • Alcohol. Some studies suggest a slightly higher risk of breast cancer among women who drink alcohol.

Most women who develop breast cancer have none of the risk factors listed above, other than the risk that comes with growing older. Scientists are conducting research into the causes of breast cancer to learn more about risk factors and ways of preventing this disease.

Detecting Breast Cancer

Women should talk with their doctor about factors that can increase their chance of getting breast cancer. Women of any age who are at higher risk for developing this disease should ask their doctor when to start and how often to be checked for breast cancer. Breast cancer screening has been shown to decrease the risk of dying from breast cancer.

Women can take an active part in the early detection of breast cancer by having regularly scheduled screening mammograms and clinical breast exams (breast exams performed by health professionals). Some women also perform breast self-exams.

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

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

If an area of the breast looks suspicious on the screening mammogram, additional (diagnostic) mammograms may be needed. Depending on the results, the doctor may advise the woman to have a biopsy.

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

Nevertheless, studies show that mammograms reduce the risk of dying from breast cancer. Most doctors recommend that women in their forties and older have mammograms regularly, every 1 to 2 years.

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

Recognizing Symptoms

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

  • A lump or thickening in or near the breast or in the underarm area;

  • A change in the size or shape of the breast;

  • Nipple discharge or tenderness, or the nipple pulled back (inverted) into the breast;

  • Ridges or pitting of the breast (the skin looks like the skin of an orange); or

  • A change in the way the skin of the breast, areola, or nipple looks or feels (for example, warm, swollen, red, or scaly).

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

Diagnosing Breast Cancer

To help find the cause of any sign or symptom, a doctor does a careful physical exam and asks about personal and family medical history. In addition, the doctor may do one or more breast exams:

  • Clinical breast exam. The doctor can tell a lot about a lump by carefully feeling it and the tissue around it. Benign lumps often feel different from cancerous ones. The doctor can examine the size and texture of the lump and determine whether the lump moves easily.

  • Mammography. X-rays of the breast can give the doctor important information about a breast lump.

  • Ultrasonography. Using high-frequency sound waves, ultrasonography can often show whether a lump is a fluid-filled cyst (not cancer) or a solid mass (which may or may not be cancer). This exam may be used along with mammography.

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

Biopsy

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

  • Fine-needle aspiration. A thin needle is used to remove fluid and/or cells from a breast lump. If the fluid is clear, it may not need to be checked by a lab.

  • Needle biopsy. Using special techniques, tissue can be removed with a needle from an area that looks suspicious on a mammogram but cannot be felt. Tissue removed in a needle biopsy goes to a lab to be checked by a pathologist for cancer cells.

  • Surgical biopsy. In an incisional biopsy, the surgeon cuts out a sample of a lump or suspicious area. In an excisional biopsy, the surgeon removes all of a lump or suspicious area and an area of healthy tissue around the edges. A pathologist then examines the tissue under a microscope to check for cancer cells.

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

  • What type of biopsy will I have? Why?

  • How long will it take? Will I be awake? Will it hurt?

  • How soon will I know the results?

  • If I do have cancer, who will talk with me about treatment? When?

When Cancer Is Found

The most common type of breast cancer is ductal carcinoma. It begins in the lining of the ducts. Another type, called lobular carcinoma, arises in the lobules. When cancer is found, the pathologist can tell what kind of cancer it is (whether it began in a duct or a lobule) and whether it is invasive (has invaded nearby tissues in the breast).

Special lab tests of the tissue help the doctor learn more about the cancer. For example, hormone receptor tests (estrogen and progesterone receptor tests) can help determine whether hormones help the cancer to grow. If test results show that hormones do affect the cancer's growth (a positive test result), the cancer is likely to respond to hormonal therapy. This therapy deprives the cancer cells of estrogen. More information about hormonal therapy can be found in the "Planning Treatment" section.

Other tests are sometimes done to help the doctor predict whether the cancer is likely to progress. For example, the doctor may order x-rays and lab tests. Sometimes a sample of breast tissue is checked for a gene (the human epidermal growth factor receptor-2 or HER-2 gene) that is associated with a higher risk that the breast cancer will come back. The doctor may also order special exams of the bones, liver, or lungs because breast cancer may spread to these areas.

If the diagnosis is breast cancer, a woman may want to ask these questions:

  • What kind of breast cancer do I have?

  • What did the hormone receptor test show? What other lab tests were done on the tumor tissue, and what did they show?

  • How will you determine whether the disease has spread?

  • How will this information help in deciding what type of treatment or further tests will be best for me?

Planning Treatment

Many women with breast cancer want to take an active part in decisions about their medical care. They want to learn all they can about their disease and their treatment choices. However, the shock and stress that people often feel after a diagnosis of cancer can make it hard for them to think of everything they want to ask the doctor. Often it is helpful to prepare a list of questions in advance. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some people also want to have a family member or friend with them when they talk to the doctor -- to take part in the discussion, to take notes, or just to listen.

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

Second Opinion

Before starting treatment, the patient might want a second opinion about the diagnosis and the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if the woman requests it. It may take a little while to arrange to see another doctor. In most cases, a brief delay (up to 3 or 4 weeks) between biopsy and treatment does not make breast cancer treatment less effective. There are a number of ways to find a doctor for a second opinion:

  • The patient's doctor may refer her to one or more specialists. Specialists who treat women with breast cancer include surgeons, medical oncologists, plastic surgeons, and radiation oncologists. At cancer centers or special centers for breast diseases, these doctors often work together as a team.

  • The Cancer Information Service, at 1-800-4-CANCER, can tell callers about treatment facilities, including cancer centers and other NCI-supported programs, in their area.

  • Patients can get the names of specialists from their local medical society, a nearby hospital, or a medical school.

  • The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their speciality and their educational background. This resource, produced by the American Board of Medical Specialties (ABMS), is available in most public libraries. The ABMS also provides an online service to help people locate doctors (http://www.certifieddoctor.org/).

Methods of Treating Breast Cancer

Breast cancer may be treated with local or systemic therapy. Some patients have both kinds of treatment.

Local therapy is used to remove or destroy breast cancer in a specific area. Surgery and radiation therapy are local treatments. They are used to treat the disease in the breast. When breast cancer has spread to other parts of the body, local therapy may be used to control cancer in those specific areas, such as in the lung or bone.

Systemic treatments are used to destroy or control cancer throughout the body. Chemotherapy, hormonal therapy, and biological therapy are systemic treatments. Some patients have systemic therapy to shrink the tumor before local therapy. Others have systemic therapy to prevent the cancer from coming back, or to treat cancer that has spread.

Surgery is the most common treatment for breast cancer, and there are several types of surgery. The doctor can explain each type, discuss and compare their benefits and risks, and describe how each will affect the patient's appearance.

  • An operation to remove the cancer but not the breast is called breast-sparing surgery or breast-conserving surgery. Lumpectomy and segmental mastectomy (also called partial mastectomy) are types of breast-sparing surgery. After breast-sparing surgery, most women receive radiation therapy to destroy cancer cells that remain in the area.

  • An operation to remove the breast (or as much of the breast as possible) is a mastectomy. Breast reconstruction is often an option at the same time as the mastectomy, or later on.

  • In most cases, the surgeon also removes lymph nodes under the arm to help determine whether cancer cells have entered the lymphatic system. This is called an axillary lymph node dissection.

In lumpectomy, the surgeon removes the breast cancer and some normal tissue around it. (Sometimes an excisional biopsy serves as a lumpectomy.) Often, some of the lymph nodes under the arm are removed.

In segmental mastectomy, the surgeon removes the cancer and a larger area of normal breast tissue around it. Occasionally, some of the lining over the chest muscles below the tumor is removed as well. Some lymph nodes under the arm may also be removed.

In total (simple) mastectomy, the surgeon removes the whole breast. Some lymph nodes under the arm may also be removed.

In modified radical mastectomy, the surgeon removes the whole breast, most of the lymph nodes under the arm, and, often, the lining over the chest muscles. The smaller of the two chest muscles also may be taken out to help in removing the lymph nodes.

In radical mastectomy (also called Halsted radical mastectomy), the surgeon removes the breast, both chest muscles, all of the lymph nodes under the arm, and some additional fat and skin. For many years, this operation was considered the standard one for women with breast cancer, but it is almost never used today. In rare cases, radical mastectomy may be suggested if the cancer has spread to the chest muscles.

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

  • What kinds of surgery can I consider? Is breast-sparing surgery an option for me? Which operation do you recommend for me? What are the risks of surgery?

  • Should I store some of my own blood in case I need a transfusion?

  • Do I need my lymph nodes removed? How many? Why? What special precautions will I need to take if lymph nodes are removed?

  • How will I feel after the operation?

  • Will I need to learn how to do special things to take care of myself or my incision when I get home?

  • Where will the scars be? What will they look like?

  • If I decide to have plastic surgery to rebuild my breast, how and when can that be done? Can you suggest a plastic surgeon for me to contact?

  • Will I have to do special exercises?

  • When can I get back to my normal activities?

  • Is there someone I can talk with who has had the same treatment I'll be having?

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

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

For external radiation therapy, the patient goes to the hospital or clinic, generally 5 days a week for several weeks. For implant radiation, a patient stays in the hospital. The implants remain in place for several days. They are removed before the woman goes home.

Sometimes, depending on the size of the tumor and other factors, radiation therapy is used after surgery, especially after breast-sparing surgery. The radiation destroys any breast cancer cells that may remain in the area.

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

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

  • Why do I need this treatment?

  • What are the risks and side effects of this treatment?

  • Are there any long-term effects?

  • When will the treatments begin? When will they end?

  • How will I feel during therapy?

  • What can I do to take care of myself during therapy?

  • Can I continue my normal activities?

  • How will my breast look afterward?

  • What are the chances that the tumor will come back in my breast?

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

Most patients have chemotherapy in an outpatient part of the hospital, at the doctor's office, or at home. Depending on which drugs are given and her general health, however, a woman may need to stay in the hospital during her treatment.

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

Biological therapy is a treatment designed to enhance the body's natural defenses against cancer. For example, Herceptin® (trastuzumab) is a monoclonal antibody that targets breast cancer cells that have too much of a protein known as human epidermal growth factor receptor-2 (HER-2). By blocking HER-2, Herceptin slows or stops the growth of these cells. Herceptin may be given by itself or along with chemotherapy.

Patients may want to ask these questions about systemic therapy (chemotherapy, hormonal therapy, or biological therapy):

  • Why do I need this treatment?

  • If I need hormonal treatment, which would be better for me, drugs or an operation?

  • What drugs will I be taking? What will they do?

  • Will I have side effects? What can I do about them?

  • How long will I be on this treatment?

Treatment Choices

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

The doctor is the best person to answer questions about treatment for a particular patient: what her treatment choices are and how successful her treatment is expected to be. Most patients also want to know how they will look after treatment and whether they will have to change their normal activities. A woman should not feel that she needs to ask all her questions or understand all the answers at once. She will have many chances to ask the doctor to explain things that are not clear and to ask for more information.

A woman may want to talk with her doctor about taking part in a clinical trial, a research study of new treatment methods. Clinical trials are an important option for women with all stages of breast cancer. The "Research on Staging and Treatment" part of "The Promise of Cancer Research" section has more information.

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

  • Stage 0 is sometimes called noninvasive carcinoma or carcinoma in situ.

    Lobular carcinoma in situ (LCIS) refers to abnormal cells in the lining of a lobule. These abnormal cells seldom become invasive cancer. However, their presence is a sign that a woman has an increased risk of developing breast cancer. This risk of cancer is increased for both breasts. Some women with LCIS may take a drug called tamoxifen, which can reduce the risk of developing breast cancer. Others may take part in studies of other promising new preventive treatments. Some women may choose not to have treatment, but to return to the doctor regularly for checkups. And, occasionally, women with LCIS may decide to have surgery to remove both breasts to try to prevent cancer from developing. (In most cases, removal of underarm lymph nodes is not necessary.)

    Ductal carcinoma in situ (DCIS) refers to abnormal cells in the lining of a duct. DCIS is also called intraductal carcinoma. The abnormal cells have not spread beyond the duct to invade the surrounding breast tissue. However, women with DCIS are at an increased risk of getting invasive breast cancer. Some women with DCIS have breast-sparing surgery followed by radiation therapy. Or they may choose to have a mastectomy, with or without breast reconstruction (plastic surgery) to rebuild the breast. Underarm lymph nodes are not usually removed. Also, women with DCIS may want to talk with their doctor about tamoxifen to reduce the risk of developing invasive breast cancer.

  • Stage I and stage II are early stages of breast cancer in which the cancer has spread beyond the lobe or duct and invaded nearby tissue. Stage I means that the tumor is no more than about an inch across and cancer cells have not spread beyond the breast. Stage II means one of the following: the tumor in the breast is less than 1 inch across and the cancer has spread to the lymph nodes under the arm; or the tumor is between 1 and 2 inches (with or without spread to the lymph nodes under the arm); or the tumor is larger than 2 inches but has not spread to the lymph nodes under the arm.

    Women with early stage breast cancer may have breast-sparing surgery followed by radiation therapy to the breast, or they may have a mastectomy, with or without breast reconstruction to rebuild the breast. These approaches are equally effective in treating early stage breast cancer. (Sometimes radiation therapy is also given after mastectomy.)

    The choice of breast-sparing surgery or mastectomy depends mostly on the size and location of the tumor, the size of the woman's breast, certain features of the cancer, and how the woman feels about preserving her breast. With either approach, lymph nodes under the arm usually are removed.

    Many women with stage I and most with stage II breast cancer have chemotherapy and/or hormonal therapy after primary treatment with surgery or surgery and radiation therapy. This added treatment is called adjuvant therapy. If the systemic therapy is given to shrink the tumor before surgery, this is called neoadjuvant therapy. Systemic treatment is given to try to destroy any remaining cancer cells and prevent the cancer from recurring, or coming back, in the breast or elsewhere.

  • Stage III is also called locally advanced cancer. In this stage, the tumor in the breast is large (more than 2 inches across) and the cancer has spread to the underarm lymph nodes; or the cancer is extensive in the underarm lymph nodes; or the cancer has spread to lymph nodes near the breastbone or to other tissues near the breast.

    Inflammatory breast cancer is a type of locally advanced breast cancer. In this type of cancer the breast looks red and swollen (or inflamed) because cancer cells block the lymph vessels in the skin of the breast.

    Patients with stage III breast cancer usually have both local treatment to remove or destroy the cancer in the breast and systemic treatment to stop the disease from spreading. The local treatment may be surgery and/or radiation therapy to the breast and underarm. The systemic treatment may be chemotherapy, hormonal therapy, or both. Systemic therapy may be given before local therapy to shrink the tumor or afterward to prevent the disease from recurring in the breast or elsewhere.

  • Stage IV is metastatic cancer. The cancer has spread beyond the breast and underarm lymph nodes to other parts of the body.

    Women who have stage IV breast cancer receive chemotherapy and/or hormonal therapy to destroy cancer cells and control the disease. They may have surgery or radiation therapy to control the cancer in the breast. Radiation may also be useful to control tumors in other parts of the body.

  • Recurrent cancer means the disease has come back in spite of the initial treatment. Even when a tumor in the breast seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained somewhere in the body after treatment.

    Most recurrences appear within the first 2 or 3 years after treatment, but breast cancer can recur many years later.

    Cancer that returns only in the area of the surgery is called a local recurrence. If the disease returns in another part of the body, the distant recurrence is called metastatic breast cancer. The patient may have one type of treatment or a combination of treatments for recurrent cancer.

Side Effects of Treatment

It is hard to protect healthy cells from the harmful effects of breast cancer treatment. Because treatment does damage healthy cells and tissues, it causes side effects. The side effects of cancer treatment depend mainly on the type and extent of the treatment. Also, the effects may not be the same for each person, and they may be different from one treatment to the next. An important part of the treatment plan is the management of side effects.

A patient's reaction to treatment is closely monitored by physical exams, blood tests, and other tests. Doctors and nurses will explain the possible side effects of treatment, and they can suggest ways to deal with problems that may occur during and after treatment. The NCI provides helpful, informative booklets about cancer treatments and coping with side effects. Patients may want to read Understanding Breast Cancer Treatment: A Guide for Patients, as well as Radiation Therapy and You, Chemotherapy and You, and Eating Hints for Cancer Patients.

Surgery

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

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

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

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

Radiation Therapy

During radiation therapy, patients may become extremely tired, especially after several treatments. This feeling may continue for a while after treatment is over. Resting is important, but doctors usually advise their patients to try to stay reasonably active, matching their activities to their energy level. It is also common for the skin in the treated area to become red, dry, tender, and itchy. The breast may feel heavy and hard, but these conditions will clear up with time. Toward the end of treatment, the skin may become moist and "weepy." Exposing this area to air as much as possible will help the skin heal. Because bras and some types of clothing may rub the skin and cause irritation, patients may want to wear loose-fitting cotton clothes. Gentle skin care is important at this time, and patients should check with their doctor before using any deodorants, lotions, or creams on the treated area. These effects of radiation therapy on the skin are temporary, and the area gradually heals once treatment is over. However, there may be a permanent change in the color of the skin.

Chemotherapy

As with radiation, chemotherapy affects normal as well as cancer cells. The side effects of chemotherapy depend mainly on the specific drugs and the dose. In general, anticancer drugs affect rapidly dividing cells. These include blood cells, which fight infection, help the blood to clot, and carry oxygen to all parts of the body. When blood cells are affected, patients are more likely to get infections, may bruise or bleed easily, and may feel unusually weak and very tired. Rapidly dividing cells in hair roots and cells that line the digestive tract may also be affected. As a result, side effects may include loss of hair, poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Many of these side effects can now be controlled, thanks to new or improved drugs. Side effects generally are short-term and gradually go away. Hair grows back, but it may be different in color and texture.

Some anticancer drugs can damage the ovaries. If the ovaries fail to produce hormones, the woman may have symptoms of menopause, such as hot flashes and vaginal dryness. Her periods may become irregular or may stop, and she may not be able to become pregnant. Other long-term side effects are quite rare, but there have been cases in which the heart is weakened, and second cancers such as leukemia (cancer of the blood cells) have occurred.

Women who are still menstruating may still be able to get pregnant during treatment. Because the effects of chemotherapy on an unborn child are not known, it is important for a woman to talk with her doctor about birth control before treatment begins. After treatment, some women regain their ability to become pregnant, but in women over the age of 35, infertility is likely to be permanent.

Hormonal Therapy

The side effects of hormonal therapy depend largely on the specific drug or type of treatment. Tamoxifen is the most common hormonal treatment. This drug blocks the cancer cells' use of estrogen but does not stop estrogen production. Tamoxifen may cause hot flashes, vaginal discharge or irritation, nausea, and irregular periods. Women who are still menstruating and having irregular periods may become pregnant more easily when taking tamoxifen. They should discuss birth control methods with their doctor.

Serious side effects of tamoxifen are rare. It can cause blood clots in the veins, especially in the legs and in the lungs, and in a small number of women, it can slightly increase the risk of stroke. Also, tamoxifen can cause cancer of the lining of the uterus. Any unusual vaginal bleeding should be reported to the doctor. The doctor may do a pelvic exam, as well as a biopsy of the lining of the uterus, or other tests. (This does not apply to women who have had a hysterectomy, surgery to remove the uterus.)

Young women whose ovaries are removed to deprive the cancer cells of estrogen experience menopause immediately. Their symptoms are likely to be more severe than symptoms associated with natural menopause.

Biological Therapy

The side effects of biological therapy differ with the types of substances used, and from patient to patient. Rashes or swelling where the biological therapy is injected are common. Flu-like symptoms also may occur.

Herceptin may cause these and other side effects, but these effects generally become less severe after the first treatment. Less commonly, Herceptin can also cause damage to the heart that can lead to heart failure. It can also affect the lungs, causing breathing problems that require immediate medical attention. For these reasons, women are checked carefully for heart and lung problems before taking Herceptin. Patients who do take it are watched carefully during treatment.

Breast Reconstruction

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

Various procedures are used to reconstruct the breast. Some use implants (either saline or silicone); others use tissue moved from another part of the woman's body. The safety of silicone breast implants has been under review by the Food and Drug Administration (FDA) for several years. Women interested in having silicone implants should talk with their doctor about the FDA's findings and the availability of silicone implants. Which type of reconstruction is best depends on a woman's age, body type, and the type of surgery she had. A woman should ask the plastic surgeon to explain the risks and benefits of each type of reconstruction. The National Cancer Institute booklet Understanding Breast Cancer Treatment: A Guide for Patients contains more information about breast reconstruction. The Cancer Information Service at 1-800-4-CANCER can suggest other sources of information about breast reconstruction and can talk with callers about breast cancer support groups.

Rehabilitation

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

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

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

Followup Care

Regular followup exams are important after breast cancer treatment. Regular checkups ensure that changes in health are noticed. Followup exams usually include examination of the breasts, chest, neck, and underarm areas, as well as periodic mammograms. If a woman has a breast implant, special mammogram techniques can be used. Sometimes the doctor may order other imaging procedures or lab tests.

A woman who has had cancer in one breast should report any changes in the treated area or in the other breast to her doctor right away. Because a woman who has had breast cancer is at risk of getting cancer in the other breast, mammograms are an important part of followup care.

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

Support for Women with Breast Cancer

The diagnosis of breast cancer can change a woman's life and the lives of those close to her. These changes can be hard to handle. It is common for the woman and her family and friends to have many different and sometimes confusing emotions. Having helpful information and support services can make it easier to cope with these problems.

People living with cancer may worry about caring for their families, keeping their jobs, or continuing daily activities. Concerns about tests, treatments, hospital stays, and medical bills are also common. Doctors, nurses, and other members of the health care team can answer questions about treatment, working, or other activities. Meeting with a social worker, counselor, or member of the clergy can be helpful to people who want to talk about their feelings or discuss their concerns. Often, a social worker can suggest resources for help with rehabilitation, emotional support, financial aid, transportation, or home care.

Friends and relatives can be very supportive. Also, it helps many patients to discuss their concerns with others who have cancer. Women with breast cancer often get together in support groups, where they can share what they have learned about coping with their disease and the effects of their treatment. It is important to keep in mind, however, that each person is different. Treatments and ways of dealing with cancer that work for one person may not be right for another -- even if they both have the same kind of cancer. It is always a good idea to discuss the advice of friends and family members with the doctor.

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

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

Several useful National Cancer Institute booklets and other materials are available from the Cancer Information Service and through other sources listed in the "National Cancer Institute Information Resources" section. The Cancer Information Service can also provide information to help patients and their families locate programs and services.

The Promise of Cancer Research

Doctors all over the country are conducting many types of clinical trials (research studies in which people take part voluntarily). These include studies of ways to prevent, detect, diagnose, and treat breast cancer; studies of the psychological effects of the disease; and studies of ways to improve comfort and quality of life. Research already has led to significant advances in these areas, and researchers continue to search for more effective approaches.

People who take part in clinical trials have the first chance to benefit from new approaches. They also make important contributions to medical science. Although clinical trials may pose some risks, researchers take very careful steps to protect people who take part.

Women who are interested in being part of a clinical trial should talk with their doctor. They may want to read the National Cancer Institute booklets Taking Part in Clinical Trials: What Cancer Patients Need To Know or Taking Part in Clinical Trials: Cancer Prevention Studies, which describe how research studies are carried out and explain their possible benefits and risks. NCI's Web site at http://www.nci.nih.gov/ provides general information about clinical trials. It also offers detailed information about specific ongoing studies of breast cancer by linking to PDQ®, a cancer information database developed by the NCI.

Causes and Prevention

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

Scientists are trying to learn more about factors that increase the risk of developing this disease. For example, they are looking at whether the risk of breast cancer might be affected by environmental factors. So far, scientists do not have enough information to know whether any factors in the environment increase the risk of this disease. (The main known risk factors are listed in the "Breast Cancer: Who's at Risk?" section.)

Some aspects of a woman's lifestyle may affect her chances of developing breast cancer. For example, recent studies suggest that regular exercise may decrease the risk in younger women. Also, some evidence suggests a link between diet and breast cancer. Ongoing studies are looking at ways to prevent breast cancer through changes in diet or with dietary supplements. However, it is not yet known whether specific dietary changes will actually prevent breast cancer. These are active areas of research.

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

Research has led to the identification of changes (mutations) in certain genes that increase the risk of developing breast cancer. Women with a strong family history of breast cancer may choose to have a blood test to see if they have inherited a change in the BRCA1 or BRCA2 gene. Women who are concerned about an inherited risk for breast cancer should talk to their doctor. The doctor may suggest seeing a health professional trained in genetics. Genetic counseling can help a woman decide whether testing would be appropriate for her. Also, counseling before and after testing helps women understand and deal with the possible results of a genetic test. Counseling can also help with concerns about employment or about health, life, and disability insurance. The Cancer Information Service can supply additional material on genetic testing.

Scientists are looking for drugs that may prevent the development of breast cancer. In one large study, the drug tamoxifen reduced the number of new cases of breast cancer among women at an increased risk for the disease. Doctors are now studying how another drug called raloxifene compares to tamoxifen. This study is called STAR (Study of Tamoxifen and Raloxifene). For more information about prevention clinical trials, call the Cancer Information Service or refer to one of the other sources listed under "National Cancer Institute Information Resources."

Detection and Diagnosis

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

In addition, researchers are studying tumor markers. These are substances that may be present in abnormal amounts in people with cancer. Tumor markers may be found in blood or urine, or in fluid from the breast (nipple aspirate). Some of these markers may be used to check women who have already been diagnosed with breast cancer. At this time, however, no tumor marker test is reliable enough to be used routinely to detect breast cancer.

Treatment

Through research, doctors try to find new, more effective ways to treat cancer. Many studies of new approaches for patients with breast cancer are under way. When laboratory research shows that a new treatment method has promise, cancer patients receive the new approach in treatment clinical trials. These studies are designed to answer important questions and to find out whether the new approach is safe and effective. Often, clinical trials compare a new treatment with a standard approach.

Researchers are testing new anticancer drugs, doses, and treatment schedules. They are working with various drugs and drug combinations, as well as with several types of hormonal therapy. They also are looking at the effectiveness of using chemotherapy before surgery (called neoadjuvant chemotherapy) and at new ways of combining treatments, such as adding hormonal therapy or radiation therapy to chemotherapy.

New biological approaches also are under study. For example, several cancer vaccines have been designed to stimulate the immune system to mount a response against breast cancer cells. Combinations of biological treatments with other agents are also undergoing clinical study.

Researchers are exploring ways to reduce the side effects of treatment (such as lymphedema from surgery), improve the quality of patients' lives, and reduce pain. One procedure under study is called sentinel lymph node biopsy. Researchers are trying to learn whether this procedure may reduce the number of lymph nodes that must be removed during breast cancer surgery. Before surgery, the doctor injects a radioactive substance near the tumor. The substance flows through the lymphatic system to the first lymph node or nodes where cancer cells are likely to have spread (the "sentinel" node or nodes). The doctor uses a scanner to locate the radioactive substance in the sentinel nodes. Sometimes the doctor also injects a blue dye near the tumor. The dye travels through the lymphatic system to collect in the sentinel nodes. The surgeon makes a small incision and removes only the nodes with radioactive substance or blue dye. A pathologist checks the sentinel lymph nodes for cancer cells. If no cancer cells are detected, it may not be necessary to remove additional nodes. If sentinel lymph node biopsy proves to be as effective as the standard axillary lymph node dissection, the new procedure could prevent lymphedema.

Chemotherapy can reduce the ability of bone marrow to make blood cells. That is why researchers are studying ways to help the blood cells recover so that high doses of chemotherapy can be given. These studies use biological therapies (known as colony-stimulating factors), autologous bone marrow transplants, or peripheral stem cell transplants.

National Cancer Institute Booklets

The National Cancer Institute (NCI) booklets listed below and other materials are available from the Cancer Information Service by calling 1-800-4-CANCER. They are also available on the NCI Web site, which is located at http://www.nci.nih.gov/publications on the Internet.

Booklets About Breast Changes, Breast Cancer Screening, and Breast Cancer Risk

Booklets About Cancer Treatment

Booklets About Living With Cancer

National Cancer Institute Information Resources

You may want more information for yourself, your family, and your doctor. The following National Cancer Institute (NCI) services are available to help you.

Telephone

Cancer Information Service (CIS)
Provides accurate, up-to-date information on cancer to patients and their families, health professionals, and the general public. Information specialists translate the latest scientific information into understandable language and respond in English, Spanish, or on TTY equipment.

Toll-free: 1-800-4-CANCER (1-800-422-6237)
TTY (for deaf and hard of hearing callers): 1-800-332-8615

Internet

http://cancer.gov/
NCI's Web site contains comprehensive information about cancer causes and prevention, screening and diagnosis, treatment and survivorship; clinical trials; statistics; funding, training, and employment opportunities; and the Institute and its programs.

Fax

CancerFax®
Includes NCI information about cancer treatment, screening, prevention, genetics, and supportive care. To obtain a contents list, dial 1-800-624-2511 or 301-402-5874 from your touch tone phone or fax machine hand set and follow the recorded instructions.

See the complete index of What You Need To Know AboutTM Cancer publications.

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