Treatment
Side Effects of Cancer Treatment
Complementary and Alternative Medicine
Breast Reconstruction
Recovery
Follow-up Care

Treatment

Many women with breast cancer want to learn all they can about their disease and their treatment choices. They want to take an active part in making decisions about their medical care. Learning more about the disease helps many women cope. But how much information to seek and how to deal with it are personal choices. Each woman can make her own decision about how much she wants to know. (See National Cancer Institute Information Resources.)

The shock and stress after a diagnosis of cancer can make it hard to think of everything to ask the doctor. Often it helps to make a list of questions before an appointment. To help remember what the doctor says, a woman can take notes or ask whether she may use a tape recorder. Some 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 doctor may refer a woman with breast cancer to a specialist, or the woman may ask for a referral. Specialists who treat breast cancer include surgeons, medical oncologists, radiation oncologists, and plastic surgeons. A woman may have a different specialist for each type of treatment.

Treatment generally begins within a few weeks after the diagnosis. Usually, there is time for a woman to talk with her doctor about treatment options, get a second opinion, and learn more about breast cancer before making a treatment decision.

Getting a Second Opinion

Before starting treatment, a woman with breast cancer may want to get a second opinion about her diagnosis and treatment options. Some insurance companies require a second opinion; others may cover a second opinion if the woman or doctor requests it. It may take time and effort to gather medical records (mammogram films, biopsy slides, pathology report, and proposed treatment plan) and arrange to see another doctor. In general, taking several weeks to get a second opinion does not make treatment less effective.

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

• The woman's doctor may refer her to one or more specialists. At cancer centers, several specialists often work together as a team.
• The Cancer Information Service, at 1-800-4-CANCER, can tell callers about nearby treatment centers.
• 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 met certain education and training requirements and have passed specialty examinations. The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and their educational background. The directory is available in most public libraries. Also, ABMS offers this information on the Internet at http://www.abms.org. (Click on "Who's Certified.")
• The NCI provides a helpful fact sheet on how to find a doctor called "How To Find a Doctor or Treatment Facility If You Have Cancer." It is available on the Internet at http://cancer.gov/publications.

Treatment Methods

Women with breast cancer have many treatment options. These include surgery, chemotherapy, radiation therapy, hormonal therapy, and biological therapy. These options are described below.

In most cases, the most important factor in treatment choices is the stage of the disease. See the section called Treatment Choices by Stage.

Many women receive more than one type of treatment. In addition, at any stage of disease, women with breast cancer may have treatment to control pain and other symptoms of the cancer, to relieve the side effects of treatment, and to ease emotional problems. This kind of treatment is called supportive care, symptom management, or palliative care. Information about supportive care is available on NCI's Web site at http://cancer.gov and from NCI's Cancer Information Service at 1-800-4-CANCER.

Treatment for cancer 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 but not elsewhere.
• Systemic therapy: Chemotherapy, hormonal 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.

Most women want to know how treatment may change their normal activities. They want to know how they will look during and after treatment. The doctor is the best person to describe treatment choices, side effects, and the expected results of treatment. Each woman can work with her doctor to develop a treatment plan that meets her needs and personal values.

Women do not need to ask all of their questions at once. They will have other chances to ask the doctor to explain things that are not clear and to ask for more information.

Surgery

Surgery is the most common treatment for breast cancer. There are several types of surgery. (See the pictures below.) The doctor can explain each type, discuss and compare the benefits and risks, and describe how each will affect the woman's appearance:

• Breast-sparing surgery: An operation to remove the cancer but not the breast is called breast-sparing surgery, breast-conserving surgery, lumpectomy, segmental mastectomy, or partial mastectomy.

  Through a separate incision, the surgeon often removes the underarm lymph nodes to learn whether cancer cells have entered the lymphatic system. The procedure to remove the underarm lymph nodes is called an axillary lymph node dissection.

  After breast-sparing surgery, most women receive radiation therapy to the breast to destroy 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. After surgery, the woman may receive radiation therapy.

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

A new method of checking for cancer cells in the lymph nodes is called sentinel lymph node biopsy. In this operation, a specially trained surgeon removes only one or a few lymph nodes (the sentinel nodes) instead of removing a much larger number of underarm lymph nodes. Information about ongoing studies of this new method is in The Promise of Cancer Research section.

In breast-sparing surgery, the surgeon removes the tumor in the breast and some tissue around it. (Sometimes an excisional biopsy--which removes all of the tumor--serves as a lumpectomy. Biopsy is described in the Diagnosis section.) 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 or all 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 make it easier to remove the lymph nodes.

Women may choose to have breast reconstruction (plastic surgery to rebuild the shape of the breast). It may be done at the same time as a mastectomy or later. Women considering reconstruction may wish to talk about it with a plastic surgeon before having a mastectomy. More information is in the Breast Reconstruction section.

Radiation therapy

Radiation therapy (also called radiotherapy) is the use of high-energy rays to kill cancer cells. It generally follows breast-sparing surgery. Sometimes, depending on the size of the tumor and other factors, radiation therapy also is used after mastectomy. The radiation destroys breast cancer cells that may remain in the area.

Some women have radiation therapy (alone or with chemotherapy or hormonal therapy) before surgery to destroy cancer cells and shrink tumors. This approach is most often used when the breast tumor is large or cannot easily be removed by surgery.

Doctors use two types of radiation therapy to treat breast cancer:

• External radiation: The radiation comes from a machine. For external radiation therapy, a woman with breast cancer goes to the hospital or clinic. Generally, treatments are scheduled 5 days a week for several weeks.
• Internal radiation (implant radiation): The radiation comes from radioactive material placed in thin plastic tubes put directly in the breast. For implant radiation, the woman stays in the hospital. The implants remain in place for several days. They are removed before the woman goes home.

Some women with breast cancer have both kinds of radiation therapy.

Chemotherapy

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 as a pill or by injection into a vein (IV). Either way, the drugs enter the bloodstream and travel throughout the body.

Most women with breast cancer have chemotherapy in an outpatient part of the hospital, at the doctor's office, or at home. But some women may need to stay in the hospital during chemotherapy.

Hormonal therapy

Hormonal therapy keeps cancer cells from getting the natural hormones (estrogen and progesterone) they need to grow. If lab tests show that the breast tumor has hormone receptors, the woman may have hormonal therapy. Like chemotherapy, hormonal therapy can affect cells throughout the body.

This treatment may be a medicine or surgery:

• Medicine: The doctor may suggest a drug that can block the natural hormone. One example is tamoxifen, which blocks estrogen. Another type (aromatase inhibitor) prevents the body from making the female hormone estradiol, a form of estrogen.
• Surgery: If a woman has not gone through menopause, she may have surgery to remove her ovaries. The ovaries are the main source of the body's estrogen. (After menopause, hormone production by the ovaries naturally declines so surgery would not be needed.)

Biological therapy

Biological therapy uses the body's natural ability (immune system) to fight cancer. Some women with metastatic breast cancer receive a biological therapy called Herceptin® (trastuzumab). It is a monoclonal antibody, a substance made in the laboratory that can bind 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, Herceptin can slow or stop the growth of the cancer cells.

Herceptin is injected into a vein. It may be given by itself or along with chemotherapy. Like chemotherapy and hormonal therapy, it can affect cancer cells throughout the body.

Treatment Choices by Stage

A woman's treatment options depend on the stage of her disease and the following factors:

• The size of the tumor in relation to the size of her breast
• The results of lab tests (such as whether the breast cancer cells depend on hormones to grow)
• Whether she has gone through menopause
• Her general health

The following are brief descriptions of treatments commonly used for each stage. (Other treatments may be appropriate for some women.) Clinical trials can be an option at all stages of breast cancer. See the The Promise of Cancer Research section for 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 recommend regular checkups to look 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. For that reason, a very small number of women with LCIS decide to have surgery to remove both breasts (bilateral prophylactic mastectomy) to try to prevent cancer from developing. The surgeon usually does not remove the underarm lymph nodes.

• DCIS: Most women with DCIS have breast-sparing surgery followed by radiation therapy. Some 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, and IIIA

Women with Stage I, II, or IIIA breast cancer may have a combination of treatments. Some (especially those with Stage I or II breast cancer) choose breast-sparing surgery followed by radiation therapy to the breast. 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 more than three underarm lymph nodes, or if the tumor in the breast is large.

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 (especially those with large Stage II or IIIA breast tumors) have chemotherapy before surgery. This treatment is called neoadjuvant therapy. Chemotherapy before surgery may shrink a large tumor so that breast-sparing surgery is possible.

After surgery, many women receive adjuvant therapy (chemotherapy, hormonal therapy, or both). Adjuvant therapy is used to destroy any remaining cancer cells and prevent the cancer from coming back in the breast or elsewhere.

Stages IIIB and IIIC

Women with stage IIIB (including those with inflammatory breast cancer) or stage IIIC breast cancer usually have chemotherapy.

If the chemotherapy shrinks the tumor, the doctor then may recommend additional treatment:

• Mastectomy: The surgeon removes the breast and usually the lymph nodes under the arm. After surgery, the woman may receive radiation therapy to the chest and underarm area.
• Breast-sparing surgery: The surgeon removes the cancer but not the breast. Usually, lymph nodes under the arm are removed. After surgery, the 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 additional chemotherapy, hormonal therapy, or both. Systemic 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 hormonal 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 palliative (supportive) care along with anticancer treatments intended to slow the progress of the disease. Some may receive only palliative care to manage their symptoms. Palliative care can help the woman feel better--physically and emotionally. The goal of this type of treatment is to control a woman's pain and other symptoms and to relieve the side effects of treatment (such as nausea), rather than to extend her life.

Recurrent Breast Cancer

Recurrent cancer is cancer that has come back after treatment. Treatment for the recurrent disease depends mainly on the location and extent of the cancer and on the type of treatment the woman had before.

If breast cancer comes back in the breast (and not anywhere else) after breast-sparing surgery, the woman may have a mastectomy. Chances are good that the disease will not come back again elsewhere.

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

As with Stage IV breast cancer, treatment can seldom cure cancer that recurs outside the breast. Palliative care is often an important part of the treatment plan. Many patients have palliative care to ease their symptoms while they have anticancer treatments to slow the progress of the disease. Some receive only palliative care to improve their quality of life by easing pain, nausea, and other symptoms.

Side Effects of Cancer Treatment

Because cancer treatment is likely to damage healthy cells and tissues, unwanted side effects are common. Specific side effects depend mainly on the type and extent of the treatment. Side effects may not be the same for each woman, or even for women having the same treatments. And a woman's side effects may change from one treatment session to the next. The health care provider will explain the possible side effects of treatment and how to manage them.

The NCI provides helpful booklets about treatments and coping with side effects, such as Radiation Therapy and You, Chemotherapy and You, and Eating Hints for Cancer Patients. See the National Cancer Institute Information Resources and National Cancer Institute Booklets for other sources of information about side effects.

Surgery

Surgery causes short-term pain and tenderness in the area of the operation. Before surgery, women may want to talk with their health care provider about pain management. Any kind of surgery also carries a risk of infection, bleeding, or other problems. Women who develop any problems should tell their health care provider right away.

Removal of one or both breasts can cause a woman to feel off 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 feel tight. The muscles of the arm and shoulder may feel stiff and weak, but these problems usually 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 her 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.

Lymphedema

Removing the lymph nodes under the arm slows the flow of lymph fluid. The fluid may build up in the arm and hand and cause swelling (lymphedema). This problem can develop right after surgery or months to years later. A woman needs to protect her arm and hand on the treated side for the rest of her life. She will need to:

• Avoid wearing tight clothing or jewelry on her affected arm
• Carry her purse or luggage with the other arm
• Use an electric razor to avoid cuts when shaving her underarm
• Have shots, blood tests, and blood pressure measurements on the other arm
• Wear gloves to protect her hands when gardening and when using strong detergents
• Have careful manicures and avoid cutting her cuticles
• Avoid burns or sunburns to her affected arm and hand

A woman should ask her doctor how to handle any cuts, insect bites, sunburn, or other injuries to the arm or hand. Also, she should contact the doctor if that arm or hand is injured, swells, or becomes red and warm.

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 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.

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

Radiation Therapy

During radiation therapy, women with breast cancer may become tired, especially toward the end of treatment. This feeling may continue for a while after treatment is over. Resting is important, but doctors usually advise patients to try to stay as active as they can.

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

Because bras and some other types of clothing may rub the skin and cause irritation, women may want to wear loose-fitting cotton clothes during this time. Gentle skin care also is important, and women 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 lasting change in the color of the skin.

Chemotherapy

As with radiation, chemotherapy affects normal cells as well as cancer cells. The side effects of chemotherapy depend mainly on the specific drugs and the dose. In general, anticancer drugs affect cells that divide rapidly, especially:

• Blood cells: These cells 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 very weak and tired.
• Cells in hair roots: Chemotherapy can lead to hair loss. The hair grows back, but the new hair 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. Many of these side effects can be controlled with drugs.

Some anticancer drugs can damage the ovaries. If the damaged ovaries stop making hormones, the woman may have symptoms of menopause, such as hot flashes and vaginal dryness. Her menstrual periods may become irregular or may stop, and she may become infertile (unable to become pregnant). For women over the age of 35, infertility is likely to be permanent.

On the other hand, if a woman remains fertile during chemotherapy, she may be able to become pregnant. Because the effects of chemotherapy on an unborn child are not known, a woman may wish to talk with her doctor about birth control before treatment begins.

Although long-term side effects are quite rare, there have been cases in which the heart becomes weakened. Also, second cancers, such as leukemia (cancer of the blood cells), have occurred in people who have had chemotherapy.

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. It blocks the effects of estrogen on cells. Not all women who take tamoxifen have side effects. In general, the side effects of tamoxifen are similar to some of the symptoms of menopause. The most common side effects are hot flashes and vaginal discharge. Some women experience irregular menstrual periods, headaches, fatigue, nausea and/or vomiting, vaginal dryness or itching, irritation of the skin around the vagina, and skin rash.

Women who are still menstruating may become pregnant when taking tamoxifen. Tamoxifen may harm the unborn baby. Women should discuss birth control methods with their doctor before taking tamoxifen.

Serious side effects of tamoxifen are rare. However, it can cause blood clots in the veins, especially in the legs and in the lungs. In a small number of women, tamoxifen can slightly increase the risk of stroke. Also, it can cause cancer that arises in the lining or the muscular wall 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.

If the hormonal therapy is surgery to remove the ovaries, a woman will go through menopause immediately. The side effects are likely to be more severe than problems associated with natural menopause. The health care provider can suggest ways to cope with these side effects.

Biological Therapy

Herceptin is the biological therapy used to treat some women with breast cancer that has spread. Side effects that most commonly occur during the first treatment with Herceptin are fever and chills. Other possible side effects include pain, weakness, nausea, vomiting, diarrhea, headaches, difficulty breathing, and rashes. These side effects generally become less severe after the first treatment.

Herceptin also may cause heart damage, which may lead to heart failure. It can also affect the lungs, causing breathing problems that require immediate medical attention. Before a woman receives Herceptin, the health care provider checks the woman for heart and lung problems. During treatment, the health care provider watches for signs of heart and lung problems.

Complementary and Alternative Medicine

Some women with breast cancer use complementary and alternative medicine healing approaches to reduce stress or to reduce side effects and symptoms:

• An approach is generally called complementary medicine when it is used in addition to treatments prescribed by a doctor.
• An approach is called alternative medicine when it is used instead of a standard treatment.

Some common types of complementary and alternative medicine are acupressure, acupuncture, massage therapy, herbal products, vitamins or special diets, visualization, meditation, and spiritual healing. Many women report that such approaches help them feel better.

However, some types of complementary and alternative medicine may interfere with or may be harmful when used with treatments prescribed by a doctor. Before trying any of these therapies, a woman should discuss their possible benefits and risks with her doctor.

Some types of complementary and alternative medicine may be expensive. Health insurance may not cover the cost.

Breast Reconstruction

Some women who need a mastectomy decide to have breast reconstruction, either at the same time as the mastectomy or later on. Other women prefer to wear a breast form (prosthesis). Still others decide to do nothing. All of these options have 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. A woman considering breast reconstruction should consult with a plastic surgeon before the mastectomy, even if the reconstruction would be done later on.

Various procedures are used to reconstruct the breast. Some women choose to have implants (either saline or silicone). 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.

A woman also may have breast reconstruction with tissue that is moved from another part of her body. Skin, muscle, and fat can be moved to the chest from the lower abdomen, back, or buttocks. The plastic surgeon uses this tissue to create a breast shape.

Which type of reconstruction is best depends on a woman's age, body type, and the type of surgery she had. The plastic surgeon can explain the risks and benefits of each type of reconstruction.

The Cancer Information Service at 1-800-4-CANCER can suggest other sources of information about breast reconstruction.

Recovery

Health care providers make every effort to help women with breast cancer return to their normal activities as soon as possible. Recovery is different for each woman, depending on the type of treatment, whether the disease has spread, 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. Special exercises can begin 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. It is often done under the direction of a physical therapist. Over time, exercising can be more active. Regular exercise can then become part of a woman's normal routine. (Women who have a mastectomy and immediate breast reconstruction need special exercises, which the health care provider will explain.)

Often, performing certain exercises and resting with the arm propped up on a pillow can prevent or reduce lymphedema after surgery. Information about lymphedema prevention and treatment is in the Side Effects section.

More information about recovery can be found in the NCI's booklet Facing Forward Series: Life After Cancer Treatment.

Follow-up Care

Regular checkups are important after breast cancer treatment. 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. The health care provider monitors recovery and checks for recurrence of cancer. Checkups help ensure that any changes in health are noted.

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. A woman should also report if she has any 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. Some problems may arise months or years after treatment. They may suggest that the cancer has returned, but they can also be symptoms of many other health problems. It is important to share these concerns with a health care provider so problems can be diagnosed and treated as soon as possible.

Follow-up usually includes examination of the breasts, chest, neck, and underarm areas. Because a woman who has had breast cancer is at risk of getting cancer again, she should have mammograms of the preserved breast and/or opposite breast. However, a woman usually does not need a mammogram of the reconstructed breast. Sometimes the doctor may order other imaging procedures or lab tests.

The NCI has prepared a booklet for people who have completed their treatment to help answer questions about follow-up care and other concerns. Facing Forward Series: Life After Cancer Treatment provides tips for making the best use of medical visits. It describes how to talk to the doctor about creating a plan of action for recovery and future health.

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