Breast Cancer

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What is breast cancer?

Breast cancer is a malignant tumor that forms from the uncontrolled growth of abnormal breast cells. Malignant tumors can invade and destroy surrounding tissue and spread to other parts of the body. Breast cancer usually affects tissues involved in milk production (ductal and lobular tissues). The cause of most breast cancers is unknown; however, a small percentage of breast cancers tend to cluster in families. These cancers can be caused by mutations in particular genes, such as BRCA1 or BRCA2. In some cases, genetic syndromes involving other cancers also include an increased risk of breast cancer.

Early breast cancer usually does not cause pain and may exhibit no noticeable symptoms. As the cancer progresses, signs and symptoms can include a lump or thickening in or near the breast; a change in the size or shape of the breast; nipple discharge, tenderness, or retraction (turning inward); and skin irritation, dimpling, or scaliness. These changes can also be caused by conditions other than breast cancer.

Hereditary breast cancers, which are those caused by inherited gene mutations, tend to occur earlier in life than noninherited (sporadic) cases and are more likely to involve both breasts.

How common is breast cancer?

Each year, more than 211,000 cases of invasive breast cancer are diagnosed in women in the United States. Most breast cancers occur in women, but they can also develop in men. More than 1,600 cases of male breast cancer are diagnosed each year.

An estimated 5 percent to 10 percent of all breast cancers are hereditary. Some mutations in particular genes associated with breast cancer are more common among certain geographic or ethnic groups, such as people of Ashkenazi (central or eastern European) Jewish heritage and people of Norwegian, Icelandic, or Dutch ancestry.

What genes are related to breast cancer?

Variations of the ATM, BRCA1, BRCA2, CHEK2, and RAD51 genes increase the risk of developing breast cancer.

The AR, DIRAS3, ERBB2, and TP53 genes are associated with breast cancer.

These genes provide instructions for making proteins that help regulate the growth and division of cells. Some of these proteins are involved in detecting and repairing damaged DNA. Others help the cell respond to external signals, such as hormones and growth factors. When a gene mutation alters the structure or function of these proteins, cells in the breast can grow and divide uncontrollably and form a tumor.

BRCA1 and BRCA2 are major genes related to hereditary breast cancer. People who have inherited certain mutations in these genes have a high risk of developing breast cancer, ovarian cancer, and several other types of cancer over their lifetimes. Men with BRCA1 mutations have an increased risk of developing prostate cancer. Mutations in the BRCA2 gene are associated with an increased chance of developing male breast cancer and cancers of the prostate, pancreas, gallbladder, bile duct, and gastrointestinal tract. Melanoma (an aggressive form of skin cancer) and lymphoma (a cancer of immune system cells) also are more common among people who have BRCA2 mutations.

Inherited changes in several other genes, including ATM, CHEK2, and RAD51, have been associated with an increased risk of breast cancer. Although some research suggests that certain versions of the AR gene also may be associated with breast cancer risk, several other studies have not shown this connection.

Other gene mutations are acquired during a person's lifetime and are present only in certain cells. These changes, which are called somatic mutations, are not inherited. Somatic mutations in the ERBB2 (also called Her-2/neu), DIRAS3 (formerly ARHI), and TP53 genes have been identified in some cases of breast cancer.

Additional genetic changes are likely associated with breast cancer risk; however, many of these genes have not been identified or characterized.

How do people inherit breast cancer?

The way that breast cancer risk is inherited depends on the gene involved. For example, mutations in the BRCA1 and BRCA2 genes are inherited in an autosomal dominant pattern, which means one copy of the altered gene is sufficient to increase the chance of developing cancer. In other cases, the inheritance of breast cancer risk is unclear. It is important to note that people inherit an increased risk of cancer, not the disease itself. Not all people who inherit mutations in these genes will develop cancer.

Somatic mutations (genetic changes that occur only in breast cancer cells) occur during a person's lifetime and are not inherited.

What are the risk factors for breast cancer?

No one knows the exact causes of breast cancer. Doctors often cannot explain why one woman develops breast cancer and another does not. They do know that bumping, bruising, or touching the breast does not cause cancer. And breast cancer is not contagious. You cannot catch it from another person.

Research has shown that women with certain risk factors are more likely than others to develop breast cancer. A risk factor is something that may increase the chance of developing a disease.

Studies have found the following risk factors for breast cancer:

* Age: The chance of getting breast cancer goes up as a woman gets older. Most cases of breast cancer occur in women over 60. This disease is not common before menopause.

* Personal history of breast cancer: A woman who had breast cancer in one breast has an increased risk of getting cancer in her other breast.

* Family history: A woman's risk of breast cancer is higher if her mother, sister, or daughter had breast cancer. The risk is higher if her family member got breast cancer before age 40. Having other relatives with breast cancer (in either her mother's or father's family) may also increase a woman's risk.

* Certain breast changes: Some women have cells in the breast that look abnormal under a microscope. Having certain types of abnormal cells (atypical hyperplasia and lobular carcinoma in situ [LCIS]) increases the risk of breast cancer.

* Gene changes: Changes in certain genes increase the risk of breast cancer. These genes include BRCA1, BRCA2, and others. Tests can sometimes show the presence of specific gene changes in families with many women who have had breast cancer. Health care providers may suggest ways to try to reduce the risk of breast cancer, or to improve the detection of this disease in women who have these changes in their genes. NCI offers publications on gene testing.

* Reproductive and menstrual history:

- The older a woman is when she has her first child, the greater her chance of breast cancer.

- Women who had their first menstrual period before age 12 are at an increased risk of breast cancer.

- Women who went through menopause after age 55 are at an increased risk of breast cancer.

- Women who never had children are at an increased risk of breast cancer.

- Women who take menopausal hormone therapy with estrogen plus progestin after menopause also appear to have an increased risk of breast cancer.

- Large, well-designed studies have shown no link between abortion or miscarriage and breast cancer.

* Race: Breast cancer is diagnosed more often in white women than Latina, Asian, or African American women.

* Radiation therapy to the chest: Women who had radiation therapy to the chest (including breasts) before age 30 are at an increased risk of breast cancer. This includes women treated with radiation for Hodgkin's lymphoma. Studies show that the younger a woman was when she received radiation treatment, the higher her risk of breast cancer later in life.

* Breast density: Breast tissue may be dense or fatty. Older women whose mammograms (breast x-rays) show more dense tissue are at increased risk of breast cancer.

* Taking DES (diethylstilbestrol): DES was given to some pregnant women in the United States between about 1940 and 1971. (It is no longer given to pregnant women.) Women who took DES during pregnancy may have a slightly increased risk of breast cancer. The possible effects on their daughters are under study.

* Being overweight or obese after menopause: The chance of getting breast cancer after menopause is higher in women who are overweight or obese.

* Lack of physical activity: Women who are physically inactive throughout life may have an increased risk of breast cancer. Being active may help reduce risk by preventing weight gain and obesity.

* Drinking alcohol: Studies suggest that the more alcohol a woman drinks, the greater her risk of breast cancer.

Other possible risk factors are under study. Researchers are studying the effect of diet, physical activity, and genetics on breast cancer risk. They are also studying whether certain substances in the environment can increase the risk of breast cancer.

Many risk factors can be avoided. Others, such as family history, cannot be avoided. Women can help protect themselves by staying away from known risk factors whenever possible.

But it is also important to keep in mind that most women who have known risk factors do not get breast cancer. Also, most women with breast cancer do not have a family history of the disease. In fact, except for growing older, most women with breast cancer have no clear risk factors.

What are symptoms of breast cancer?

Symptoms

Common symptoms of breast cancer include:

* A change in how the breast or nipple feels

- A lump or thickening in or near the breast or in the underarm area

- Nipple tenderness

* A change in how the breast or nipple looks

- A change in the size or shape of the breast

- A nipple turned inward into the breast

- The skin of the breast, areola, or nipple may be scaly, red, or swollen. It may have ridges or pitting so that it looks like the skin of an orange.

* Nipple discharge (fluid)

Early breast cancer usually does not cause pain. Still, a woman should see her health care provider about breast pain or any other symptom that does not go away. Most often, these symptoms are not due to cancer. Other health problems may also cause them. Any woman with these symptoms should tell her doctor so that problems can be diagnosed and treated as early as possible.

What are the diagnostic options for detecting breast cancer?

Diagnosis

If you have a symptom or screening test result that suggests cancer, your doctor must find out whether it is due to cancer or to some other cause. Your doctor may ask about your personal and family medical history. You may have a physical exam. Your doctor also may order a mammogram or other imaging procedure. These tests make pictures of tissues inside the breast. After the tests, your doctor may decide no other exams are needed. Your doctor may suggest that you have a follow-up exam later on. Or you may need to have a biopsy to look for cancer cells.

Clinical Breast Exam

Your health care provider feels each breast for lumps and looks for other problems. If you have a lump, your doctor will feel its size, shape, and texture. Your doctor will also check to see if it moves easily. Benign lumps often feel different from cancerous ones. Lumps that are soft, smooth, round, and movable are likely to be benign. A hard, oddly shaped lump that feels firmly attached within the breast is more likely to be cancer.

Diagnostic Mammogram

Diagnostic mammograms are x-ray pictures of the breast. They take clearer, more detailed images of areas that look abnormal on a screening mammogram. Doctors use them to learn more about unusual breast changes, such as a lump, pain, thickening, nipple discharge, or change in breast size or shape. Diagnostic mammograms may focus on a specific area of the breast. They may involve special techniques and more views than screening mammograms.

Ultrasound

An ultrasound device sends out sound waves that people cannot hear. The waves bounce off tissues. A computer uses the echoes to create a picture. Your doctor can view these pictures on a monitor. The pictures may show whether a lump is solid or filled with fluid. A cyst is a fluid-filled sac. Cysts are not cancer. But a solid mass may be cancer. After the test, your doctor can store the pictures on video or print them out. This exam may be used along with a mammogram.

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) uses a powerful magnet linked to a computer. MRI makes detailed pictures of breast tissue. Your doctor can view these pictures on a monitor or print them on film. MRI may be used along with a mammogram.

Biopsy

Your doctor may refer you to a surgeon or breast disease specialist for a biopsy. Fluid or tissue is removed from your breast to help find out if there is cancer.

Some suspicious areas can be seen on a mammogram but cannot be felt during a clinical breast exam. Doctors can use imaging procedures to help see the area and remove tissue. Such procedures include ultrasound-guided, needle-localized, or stereotactic biopsy.

Doctors can remove tissue from the breast in different ways:

* Fine-needle aspiration: Your doctor uses a thin needle to remove fluid from a breast lump. If the fluid appears to contain cells, a pathologist at a lab checks them for cancer with a microscope. If the fluid is clear, it may not need to be checked by a lab.

* Core biopsy: Your doctor uses a thick needle to remove breast tissue. A pathologist checks for cancer cells. This procedure is also called a needle biopsy.

* Surgical biopsy: Your surgeon removes a sample of tissue. A pathologist checks the tissue for cancer cells.

- An incisional biopsy takes a sample of a lump or abnormal area.

- An excisional biopsy takes the entire lump or area.

If cancer cells are found, the pathologist can tell what kind of cancer it is. The most common type of breast cancer is ductal carcinoma. Abnormal cells are found in the lining of the ducts. Lobular carcinoma is another type. Abnormal cells are found in the lobules.

What are the treatment options for breast cancer?

Many women with breast cancer want to take an active part in making decisions about their medical care. It is natural to want to learn all you can about your disease and treatment choices. Knowing more about breast cancer helps many women cope.

Shock and stress after the diagnosis can make it hard to think of everything you want to ask your doctor. It often helps to make a list of questions before an appointment. To help remember what the doctor says, you may take notes or ask whether you may use a tape recorder. You may also want to have a family member or friend with you when you talk to the doctor - to take part in the discussion, to take notes, or just to listen. You do not need to ask all your questions at once. You will have other chances to ask your doctor or nurse to explain things that are not clear and to ask for more details.

Your doctor may refer you to a specialist, or you may ask for a referral. Specialists who treat breast cancer include surgeons, medical oncologists, and radiation oncologists. You also may be referred to a plastic surgeon.

Getting a Second Opinion

Before starting treatment, you might want a second opinion about your diagnosis and treatment plan. Many insurance companies cover a second opinion if you or your doctor requests it. It may take some time and effort to gather medical records and arrange to see another doctor. You may have to gather your mammogram films, biopsy slides, pathology report, and proposed treatment plan. Usually it is not a problem to take several weeks to get a second opinion. In most cases, the delay in starting treatment will not make treatment less effective. To make sure, you should discuss this delay with your doctor. Some women with breast cancer need treatment right away.

There are a number of ways to find a doctor for a second opinion:

* Your doctor may refer you to one or more specialists. At cancer centers, several specialists often work together as a team.

* NCI's Cancer Information Service, at 1-800-4-CANCER, can tell you about nearby treatment centers. Information Specialists also can provide online assistance through LiveHelp at http://www.cancer.gov/cis.

* A local or state medical society, a nearby hospital, or a medical school can usually provide the names of specialists.

* The American Board of Medical Specialties (ABMS) has a list of doctors who have had training and passed exams in their specialty. You can find this list in the Official ABMS Directory of Board Certified Medical Specialists. This Directory is in most public libraries. Also, ABMS offers this information at http://www.abms.org. (Click on Who's Certified.)

* NCI provides a helpful fact sheet called How To Find a Doctor or Treatment Facility If You Have Cancer.

Treatment Methods

Women with breast cancer have many treatment options. These include surgery, radiation therapy, chemotherapy, hormone therapy, and biological therapy. These options are described below. Many women receive more than one type of treatment.

The choice of treatment depends mainly on the stage of the disease. Treatment options by stage are described below.

Your doctor can describe your treatment choices and the expected results. You may want to know how treatment may change your normal activities. You may want to know how you will look during and after treatment. You and your doctor can work together to develop a treatment plan that reflects your medical needs and personal values.

Cancer treatment is either local therapy or systemic therapy:

* Local therapy: Surgery and radiation therapy are local treatments. They remove or destroy cancer in the breast. When breast cancer has spread to other parts of the body, local therapy may be used to control the disease in those specific areas.

* Systemic therapy: Chemotherapy, hormone therapy, and biological therapy are systemic treatments. They enter the bloodstream and destroy or control cancer throughout the body. Some women with breast cancer have systemic therapy to shrink the tumor before surgery or radiation. Others have systemic therapy after surgery and/or radiation to prevent the cancer from coming back. Systemic treatments also are used for cancer that has spread.

Because cancer treatments often damage healthy cells and tissues, side effects are common. Side effects depend mainly on the type and extent of the treatment. Side effects may not be the same for each woman, and they may change from one treatment session to the next.

You may want to ask your doctor these questions before your treatment begins:

* What did the hormone receptor test show? What did other lab tests show?

* Do any lymph nodes show signs of cancer?

* What is the stage of the disease? Has the cancer spread?

* What is the goal of treatment? What are my treatment choices? Which do you recommend for me? Why?

* What are the expected benefits of each kind of treatment?

* What are the risks and possible side effects of each treatment? How can side effects be managed?

* What can I do to prepare for treatment?

* Will I need to stay in the hospital? If so, for how long?

* What is the treatment likely to cost? Will my insurance cover the cost?

* How will treatment affect my normal activities?

* Would a clinical trial be appropriate for me?

Surgery

Surgery is the most common treatment for breast cancer. There are several types of surgery. (See pictures below.) Your doctor can explain each type, discuss and compare the benefits and risks, and describe how each will change the way you look:

* Breast-sparing surgery: An operation to remove the cancer but not the breast is breast-sparing surgery. It is also called breast-conserving surgery, lumpectomy, segmental mastectomy, and partial mastectomy. Sometimes an excisional biopsy serves as a lumpectomy because the surgeon removes the whole lump.

The surgeon often removes the underarm lymph nodes as well. A separate incision is made. This procedure is called an axillary lymph node dissection. It shows whether cancer cells have entered the lymphatic system.

After breast-sparing surgery, most women receive radiation therapy to the breast. This treatment destroys cancer cells that may remain in the breast.

* Mastectomy: An operation to remove the breast (or as much of the breast tissue as possible) is a mastectomy. In most cases, the surgeon also removes lymph nodes under the arm. Some women have radiation therapy after surgery.

Studies have found equal survival rates for breast-sparing surgery (with radiation therapy) and mastectomy for Stage I and Stage II breast cancer.

Sentinel lymph node biopsy is a new method of checking for cancer cells in the lymph nodes. A surgeon removes fewer lymph nodes, which causes fewer side effects. (If the doctor finds cancer cells in the axillary lymph nodes, an axillary lymph node dissection usually is done.) Information about ongoing studies of sentinel lymph node biopsy is in the section on The Promise of Cancer Research. These studies will learn the lasting effects of removing fewer lymph nodes.

In breast-sparing surgery, the surgeon removes the tumor in the breast and some tissue around it. The surgeon may also remove lymph nodes under the arm. The surgeon sometimes removes some of the lining over the chest muscles below the tumor.

In breast-sparing surgery, the surgeon removes the tumor in the breast and some tissue around it. The surgeon may also remove lymph nodes under the arm. The surgeon sometimes removes some of the lining over the chest muscles below the tumor.

In total (simple) mastectomy, the surgeon removes the whole breast. 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, and most or all of the lymph nodes under the arm. Often, the lining over the chest muscles is removed. A small chest muscles also may be taken out to make it easier to remove the lymph nodes.

In modified radical mastectomy, the surgeon removes the whole breast, and most or all of the lymph nodes under the arm. Often, the lining over the chest muscles is removed. A small chest muscles also may be taken out to make it easier to remove the lymph nodes.

You may choose to have breast reconstruction. This is plastic surgery to rebuild the shape of the breast. It may be done at the same time as a mastectomy or later. If you are considering reconstruction, you may wish to talk with a plastic surgeon before having a mastectomy. More information is in the Breast Reconstruction section.

The time it takes to heal after surgery is different for each woman. Surgery causes pain and tenderness. Medicine can help control the pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more relief. Any kind of surgery also carries a risk of infection, bleeding, or other problems. You should tell your health care provider right away if you develop any problems.

You may feel off balance if you've had one or both breasts removed. You may feel more off balance if you have large breasts. This imbalance can cause discomfort in your neck and back. Also, the skin where your breast was removed may feel tight. Your arm and shoulder muscles may feel stiff and weak. These problems usually go away. The doctor, nurse, or physical therapist can suggest exercises to help you regain movement and strength in your arm and shoulder. Exercise can also reduce stiffness and pain. You may be able to begin gentle exercises within days of surgery.

Because nerves may be injured or cut during surgery, you may have numbness and tingling in your chest, underarm, shoulder, and upper arm. These feelings usually go away within a few weeks or months. But for some women, numbness does not go away.

Removing the lymph nodes under the arm slows the flow of lymph fluid. The fluid may build up in your arm and hand and cause swelling. This swelling is lymphedema. Lymphedema can develop right after surgery or months to years later.

You will need to protect your arm and hand on the treated side for the rest of your life:

* Avoid wearing tight clothing or jewelry on your affected arm

* Carry your purse or luggage with the other arm

* Use an electric razor to avoid cuts when shaving under your arm

* Have shots, blood tests, and blood pressure measurements on the other arm

* Wear gloves to protect your hands when gardening and when using strong detergents

* Have careful manicures and avoid cutting your cuticles

* Avoid burns or sunburns to your affected arm and hand

You should ask your doctor how to handle any cuts, insect bites, sunburn, or other injuries to your arm or hand. Also, you should contact the doctor if your arm or hand is injured, swells, or becomes red and warm.

If lymphedema occurs, the doctor may suggest raising your arm above your heart whenever you can. The doctor may show you hand and arm exercises. Some women with lymphedema wear an elastic sleeve to improve lymph circulation. Medication, manual lymph drainage (massage), or use of a machine that gently compresses the arm may also help. You may be referred to a physical therapist or another specialist.

More information about lymphedema is available on NCI's Web site at http://www.cancer.gov and from Information Specialists at 1-800-4-CANCER or LiveHelp.

You may want to ask your doctor these questions before having surgery:

* What kinds of surgery can I consider? Is breast-sparing surgery an option for me? Which operation do you recommend for me? Why?

* Will my lymph nodes be removed? How many? Why?

* How will I feel after the operation? Will I have to stay in the hospital?

* Will I need to learn how to take care of myself or my incision when I get home?

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

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

* Will I have to do special exercises to help regain motion and strength in my arm and shoulder? Will a physical therapist or nurse show me how to do the exercises?

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

Radiation Therapy

Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. Most women receive radiation therapy after breast-sparing surgery. Some women receive radiation therapy after a mastectomy. Treatment depends on the size of the tumor and other factors. The radiation destroys breast cancer cells that may remain in the area.

Some women have radiation therapy before surgery to destroy cancer cells and shrink the tumor. Doctors use this approach when the tumor is large or may be hard to remove. Some women also have chemotherapy or hormone therapy before surgery.

Doctors use two types of radiation therapy to treat breast cancer. Some women receive both types:

* External radiation: The radiation comes from a large machine outside the body. Most women go to a hospital or clinic for treatment. Treatments are usually 5 days a week for several weeks.

* Internal radiation (implant radiation): Thin plastic tubes (implants) that hold a radioactive substance are put directly in the breast. The implants stay in place for several days. A woman stays in the hospital while she has implants. Doctors remove the implants before she goes home.

Side effects depend mainly on the dose and type of radiation and the part of your body that is treated.

It is common for the skin in the treated area to become red, dry, tender, and itchy. Your breast may feel heavy and tight. These problems will go away over time. Toward the end of treatment, your skin may become moist and weepy. Exposing this area to air as much as possible can help the skin heal.

Bras and some other types of clothing may rub your skin and cause soreness. You may want to wear loose-fitting cotton clothes during this time. Gentle skin care also is important. You should check with your doctor before using any deodorants, lotions, or creams on the treated area. These effects of radiation therapy on the skin will go away. The area gradually heals once treatment is over. However, there may be a lasting change in the color of your skin.

You are likely to become very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can.

Although the side effects of radiation therapy can be distressing, your doctor can usually relieve them.

You may want to ask your doctor these questions before having radiation therapy:

* How will radiation be given?

* When will treatment start? When will it end? How often will I have treatments?

* How will I feel during treatment? Will I be able to drive myself to and from treatment?

* How will we know the treatment is working?

* What can I do to take care of myself before, during, and after treatment?

* Will treatment affect my skin?

* How will my chest look afterward?

* Are there any long-term effects?

* What is the chance that the cancer will come back in my breast?

* How often will I need checkups?

Chemotherapy

Chemotherapy uses anticancer drugs to kill cancer cells. Chemotherapy for breast cancer is usually a combination of drugs. The drugs may be given as a pill or by injection into a vein (IV). Either way, the drugs enter the bloodstream and travel throughout the body.

Women with breast cancer can have chemotherapy in an outpatient part of the hospital, at the doctor's office, or at home. Some women need to stay in the hospital during treatment.

Side effects depend mainly on the specific drugs and the dose. The drugs affect cancer cells and other cells that divide rapidly:

* Blood cells: These cells fight infection, help your blood to clot, and carry oxygen to all parts of the body. When drugs affect your blood cells, you are more likely to get infections, bruise or bleed easily, and feel very weak and tired. Years after chemotherapy, some women have developed leukemia (cancer of the blood cells).

* Cells in hair roots: Chemotherapy can cause hair loss. Your hair will grow back, but it may be somewhat different in color and texture.

* Cells that line the digestive tract: Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores.

Your doctor can suggest ways to control many of these side effects.

Some drugs used for breast cancer can cause tingling or numbness in the hands or feet. This problem usually goes away after treatment is over. Other problems may not go away. In some women, the drugs used for breast cancer may weaken the heart.

Some anticancer drugs can damage the ovaries. The ovaries may stop making hormones. You may have symptoms of menopause. The symptoms include hot flashes and vaginal dryness. Your menstrual periods may no longer be regular or may stop. Some women become infertile (unable to become pregnant). For women over the age of 35, infertility is likely to be permanent.

On the other hand, you may remain fertile during chemotherapy and be able to become pregnant. The effects of chemotherapy on an unborn child are not known. You should talk to your doctor about birth control before treatment begins.

Hormone Therapy

Some breast tumors need hormones to grow. Hormone therapy keeps cancer cells from getting or using the natural hormones they need. These hormones are estrogen and progesterone. Lab tests can show if a breast tumor has hormone receptors. If you have this kind of tumor, you may have hormone therapy.

This treatment uses drugs or surgery:

* Drugs: Your doctor may suggest a drug that can block the natural hormone. One drug is tamoxifen, which blocks estrogen. Another type of drug prevents the body from making the female hormone estradiol. Estradiol is a form of estrogen. This type of drug is an aromatase inhibitor. If you have not gone through menopause, your doctor may give you a drug that stops the ovaries from making estrogen.

* Surgery: If you have not gone through menopause, you may have surgery to remove your ovaries. The ovaries are the main source of the body's estrogen. A woman who has gone through menopause does not need surgery. (The ovaries produce less estrogen after menopause.)

The side effects of hormone therapy depend largely on the specific drug or type of treatment. Tamoxifen is the most common hormone treatment. In general, the side effects of tamoxifen are similar to some of the symptoms of menopause. The most common are hot flashes and vaginal discharge. Other side effects are irregular menstrual periods, headaches, fatigue, nausea, vomiting, vaginal dryness or itching, irritation of the skin around the vagina, and skin rash. Not all women who take tamoxifen have side effects.

It is possible to become pregnant when taking tamoxifen. Tamoxifen may harm the unborn baby. If you are still menstruating, you should discuss birth control methods with your doctor.

Serious side effects of tamoxifen are rare. However, it can cause blood clots in the veins. Blood clots form most often in the legs and in the lungs. Women have a slight increase in their risk of stroke.

Tamoxifen can cause cancer of the uterus. Your doctor should perform regular pelvic exams. You should tell your doctor about any unusual vaginal bleeding between exams.

When the ovaries are removed, menopause occurs at once. The side effects are often more severe than those caused by natural menopause. Your health care provider can suggest ways to cope with these side effects.

Biological Therapy

Biological therapy helps the immune system fight cancer. The immune system is the body's natural defense against disease.

Some women with breast cancer that has spread receive a biological therapy called Herceptin? (trastuzumab). It is a monoclonal antibody. It is made in the laboratory and binds to cancer cells.

Herceptin is given to women whose lab tests show that a breast tumor has too much of a specific protein known as HER2. By blocking HER2, it can slow or stop the growth of the cancer cells.

Herceptin is given by vein. It may be given alone or with chemotherapy.

The first time a woman receives Herceptin, the most common side effects are fever and chills. Some women also have pain, weakness, nausea, vomiting, diarrhea, headaches, difficulty breathing, or rashes. Side effects usually become milder after the first treatment.

Herceptin also may cause heart damage. This may lead to heart failure. Herceptin can also affect the lungs. It can cause breathing problems that require a doctor at once. Before you receive Herceptin, your doctor will check for your heart and lungs. During treatment, your doctor will watch for signs of lung problems.

You may want to ask your doctor these questions before having chemotherapy, hormone therapy, or biological therapy:

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

* If I need hormone treatment, would you recommend drugs or surgery to remove my ovaries?

* When will treatment start? When will it end? How often will I have treatments?

* Where will I go for treatment? Will I be able to drive home afterward?

* What can I do to take care of myself during treatment?

* How will we know the treatment is working?

* Which side effects should I tell you about?

* Will there be long-term effects?

Treatment Choices by Stage

Your treatment options depend on the stage of your disease and these factors:

* The size of the tumor in relation to the size of your breast

* The results of lab tests (such as whether the breast cancer cells need hormones to grow)

* Whether you have gone through menopause

* Your general health

Below are brief descriptions of common treatments for each stage. Other treatments may be appropriate for some women. Clinical trials can be an option at all stages of breast cancer. The Promise of Cancer Research section has information about clinical trials.

Stage 0

Stage 0 breast cancer refers to lobular carcinoma in situ (LCIS) or ductal carcinoma in situ (DCIS):

* LCIS: Most women with LCIS do not have treatment. Instead, the doctor may suggest regular checkups to watch for signs of breast cancer.

Some women take tamoxifen to reduce the risk of developing breast cancer. Others may take part in studies of promising new preventive treatments.

Having LCIS in one breast increases the risk of cancer for both breasts. A very small number of women with LCIS try to prevent cancer with surgery to remove both breasts. This is a bilateral prophylactic mastectomy. The surgeon usually does not remove the underarm lymph nodes.

* DCIS: Most women with DCIS have breast-sparing surgery followed by radiation therapy. Some women choose to have a total mastectomy. Underarm lymph nodes are not usually removed. Women with DCIS may receive tamoxifen to reduce the risk of developing invasive breast cancer.

Stages I, II, IIIA, and Operable IIIC

Women with Stage I, II, IIIA, and operable (can treat with surgery) IIIC breast cancer may have a combination of treatments. Some may have breast-sparing surgery followed by radiation therapy to the breast. This choice is common for women with Stage I or II breast cancer. Others decide to have a mastectomy.

With either approach, women (especially those with Stage II or IIIA breast cancer) often have lymph nodes under the arm removed. The doctor may suggest radiation therapy after mastectomy if cancer cells are found in 1 to 3 lymph nodes under the arm, or if the tumor in the breast is large. If cancer cells are found in more than 3 lymph nodes under the arm, the doctor usually will suggest radiation therapy after mastectomy.

The choice between breast-sparing surgery (followed by radiation therapy) and mastectomy depends on many factors:

* The size, location, and stage of the tumor

* The size of the woman's breast

* Certain features of the cancer

* How the woman feels about saving her breast

* How the woman feels about radiation therapy

* The woman's ability to travel to a radiation treatment center

Some women have chemotherapy before surgery. This is neoadjuvant therapy (treatment before the main treatment). Chemotherapy before surgery may shrink a large tumor so that breast-sparing surgery is possible. Women with large Stage II or IIIA breast tumors often choose this treatment.

After surgery, many women receive adjuvant therapy. Adjuvant therapy is treatment given after the main treatment to increase the chances of a cure. Radiation treatment can kill cancer cells in and near the breast. Women also may have systemic treatment such as chemotherapy, hormone therapy, or both. This treatment can destroy cancer cells that remain anywhere in the body. It can prevent the cancer from coming back in the breast or elsewhere.

Stages IIIB and Inoperable IIIC

Women with Stage IIIB (including inflammatory breast cancer) or inoperable Stage IIIC breast cancer usually have chemotherapy. (Inoperable cancer means it cannot be treated with surgery.)

If the chemotherapy shrinks the tumor, the doctor then may suggest further treatment:

* Mastectomy: The surgeon removes the breast. In most cases, the lymph nodes under the arm are removed. After surgery, a woman may receive radiation therapy to the chest and underarm area.

* Breast-sparing surgery: The surgeon removes the cancer but not the breast. In most cases, the lymph nodes under the arm are removed. After surgery, a woman may receive radiation therapy to the breast and underarm area.

* Radiation therapy instead of surgery: Some women have radiation therapy but no surgery. The doctor also may recommend more chemotherapy, hormone therapy, or both. This therapy may help prevent the disease from coming back in the breast or elsewhere.

Stage IV

In most cases, women with Stage IV breast cancer have hormone therapy, chemotherapy, or both. Some also may have biological therapy. Radiation may be used to control tumors in certain parts of the body. These treatments are not likely to cure the disease, but they may help a woman live longer.

Many women have supportive care along with anticancer treatments. Anticancer treatments are given to slow the progress of the disease. Supportive care helps manage pain, other symptoms, or side effects (such as nausea). It does not aim to extend a woman's life. Supportive care can help a woman feel better physically and emotionally. Some women with advanced cancer decide to have only supportive care.

Recurrent Breast Cancer

Recurrent cancer is cancer that has come back after it could not be detected. Treatment for the recurrent disease depends mainly on the location and extent of the cancer. Another main factor is the type of treatment the woman had before.

If breast cancer comes back only in the breast after breast-sparing surgery, the woman may have a mastectomy. Chances are good that the disease will not come back again.

If breast cancer recurs in other parts of the body, treatment may involve chemotherapy, hormone therapy, or biological therapy. Radiation therapy may help control cancer that recurs in the chest muscles or in certain other areas of the body.

Treatment can seldom cure cancer that recurs outside the breast. Supportive care is often an important part of the treatment plan. Many patients have supportive care to ease their symptoms and anticancer treatments to slow the progress of the disease. Some receive only supportive care to improve their quality of life.

Follow-up Care

Follow-up care after treatment for breast cancer is important. Recovery is different for each woman. Your recovery depends on your treatment, whether the disease has spread, and other factors.

Even when the cancer seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained somewhere in the body after treatment. Your doctor will monitor your recovery and check for recurrence of the cancer.

You should report any changes in the treated area or in your other breast to the doctor right away. Tell your doctor about any health problems, such as pain, loss of appetite or weight, changes in menstrual cycles, unusual vaginal bleeding, or blurred vision. Also talk to your doctor about headaches, dizziness, shortness of breath, coughing or hoarseness, backaches, or digestive problems that seem unusual or that don't go away. Such problems may arise months or years after treatment. They may suggest that the cancer has returned, but they can also be symptoms of other health problems. It is important to share your concerns with your doctor so problems can be diagnosed and treated as soon as possible.

Follow-up exams usually include the breasts, chest, neck, and underarm areas. Since you are at risk of getting cancer again, you should have mammograms of your preserved breast and your other breast. You probably will not need a mammogram of a reconstructed breast or if you had a mastectomy without reconstruction. Your doctor may order other imaging procedures or lab tests.

Sources of Support

Learning you have breast cancer can change your life and the lives of those close to you. These changes can be hard to handle. It is normal for you, your family, and your friends to have many different and sometimes confusing feelings.

You may worry about caring for your family, keeping your job, or continuing daily activities. Concerns about treatments and managing side effects, 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 if you want to talk about your feelings or concerns. Often, a social worker can suggest resources for financial aid, transportation, home care, or emotional support.

Friends and relatives can be very supportive. Also, you may find it helps to discuss your concerns with others who have cancer. Women with breast cancer often get together in support groups to share what they have learned about coping with their disease and the effects of their treatment. It is important to keep in mind, however, that each woman is different. Ways that one woman deals with cancer may not be right for another. You may want to ask your health care provider about advice you receive from other women with breast cancer.

Several organizations offer special programs for women with breast cancer. Women who have had the disease serve as trained volunteers. They may talk with or visit women with breast cancer, provide information, and lend emotional support. They often share their experiences with breast cancer treatment, breast reconstruction, and recovery.

You may be afraid that changes to your body will affect not only how you look but also how other people feel about you. You may worry that breast cancer and its treatment will affect your sexual relationships. Many couples find it helps to talk about their concerns. Some find that counseling or a couples' support group can be helpful.

Source: National Institutes of Health

Studies from University of California have provided new information about breast cancer therapy

"Intraoperative touch preparations have been used in the past but can be difficult to interpret without an experienced cytopathologist. The objective of this study is to examine the reliability of enhanced intraoperative touch preps (EIOTP) compared with final pathologic margins. We prospectively performed EIOTP on 20 tumors in women undergoing breast conservation therapy. Six margins and the main tumor were touched onto poly-L-lysine coated slides. The slides were stained with anti MUC1 and anti-E-cadherin antibodies, and Hoechst nuclear stain. A parallel set of slides were stained with hematoxylin and eosin for comparison. The EIOTP results were compared with pathologic interpretation of paraffin embedded permanent sections. A total of 120 margins underwent EIOTP in 20 patients. We found a sensitivity equal to 80 per cent, specificity 100 per cent, positive predictive value 100 per cent, and negative predictive value 99 per cent. EIOTP in conjunction with MUC-1 and E-cadherin by immunofluorescence is a sensitive and highly specific mechanism to identify cancer cells at breast tissue margins," wrote S.L. Blair and colleagues, University of California.

The researchers concluded: "The immunofluorescence stains may help the pathologist to identify cancer cells in fresh breast tissue and limit breast re-excisions in the future."

Blair and colleagues published their study in The American Surgeon (Enhanced touch preps improve the ease of interpretation of intraoperative breast cancer margins. The American Surgeon, 2007;73(10):973-6).

For additional information, contact S.L. Blair, University of California San Diego, Dept. of Surgery and Pathology, La Jolla, California 92093-0987 USA..

Publisher contact information for the journal The American Surgeon is: Southeastern Surgical Congress, 141 West Wieuca Rd., Ste. B100, Atlanta, GA 30342, USA.

Keywords: United States, La Jolla, Breast Cancer Therapy, Breast Cancer, Breast Carcinoma, Oncology, Therapy, Treatment, Women's Health.

This article was prepared by Biotech Business Week editors from staff and other reports. Copyright 2007, Biotech Business Week via NewsRx.com.