Breast Cancer

What is breast cancer?
Breast cancer happens when normal cells in the breast change and grow out of control. Women sometimes discover they have breast cancer because they find a lump in one of their breasts. Breast cancer is much more common in women than in men. But men can get the disease. Breast cancer sometimes runs in families.
If you feel a lump in your breast, see your doctor or nurse right away. Breast lumps can be caused by conditions that are not cancer. But it is a good idea to have any lumps checked out.
  • Is there a test for breast cancer? — Yes. Doctors use a special kind of x-ray called a mammogram to check for breast cancer. If a mammogram finds a spot that looks like it could be cancer, doctors usually follow up with another test called a biopsy. During a biopsy, a doctor takes one or more small samples of tissue from the breast. That way the doctor can look at the cells under a microscope to see if they have cancer.
  • What is breast cancer staging? — Cancer staging is a way in which doctors find out how far a cancer has spread. The right treatment for you will depend, in part, on the stage of your cancer.

How is breast cancer treated?

Most people with breast cancer have one or more of the following treatments:

  • Surgery — Breast cancer is usually treated with surgery to remove the cancer. Many women with breast cancer can choose between mastectomy and breast conserving therapy (also called “lumpectomy”).
  • Mastectomy — is surgery to remove the whole breast. (If you choose this option, you might have to decide whether to have surgery to reconstruct your breast and when.
  • Breast conserving therapy — (lumpectomy) is surgery to remove the cancer and a section of healthy tissue around it. Women who choose this option keep their breast. But they usually must have radiation therapy after surgery.
  • Radiation therapy — Radiation kills cancer cells.
  • Chemotherapy — Chemotherapy is the term doctors use to describe a group of medicines that kill cancer cells. Some women take these medicines before surgery to shrink the cancer and make it easier to remove. Some women take these medicines after surgery to keep cancer from growing, spreading, or coming back.
  • Hormone therapy —Some forms of breast cancer grow in response to hormones. Your doctor might give you treatments to block hormones or to prevent your body from making certain kinds of hormones.
  • Targeted therapy —Some medicines work only on cancers that have certain characteristics. Your doctor might test you to see if you have a kind of cancer that would respond to this kind of therapy.

What happens after treatment?

After treatment, you will need to be checked every so often to see if the cancer comes back. You will have tests, usually including more mammograms. You should also watch for symptoms that could mean the cancer has come back. Examples of these symptoms include new lumps in the breast area, pain (in the bones, chest, or stomach), trouble breathing, and headaches. If you start having any new symptom, mention it to your doctor.

What happens if cancer comes back or spreads?

That depends on where the cancer is. Most people get hormone therapy or chemotherapy. Some people also have surgery to remove new tumors.

Can breast cancer be prevented?

Women who are at high risk of getting breast cancer can sometimes take a medicine to help prevent the disease. If you have a strong family history of breast cancer, ask your doctor what you can do to prevent cancer.

What will my life be like?

Many people with breast cancer do very well after treatment. The important thing is to take your medicines as directed and to follow all your doctors’ instructions about visits and tests. It’s also important to talk to your doctor about any side effects or problems you have during treatment.
Getting treated for breast cancer involves making many choices. Besides choosing which surgery to have, you might have to choose which medicines to take and when.
Always let your doctors and nurses know how you feel about a treatment. Any time you are offered a treatment, ask:

  • What are the benefits of this treatment? Is it likely to help me live longer? Will it reduce or prevent symptoms?
  • What are the downsides to this treatment?
  • Are there alternatives to this treatment?
  • What happens if I do not have this treatment?

What are the treatment choices for early-stage breast cancer?

Only your doctor can tell you what your treatment choices are. That’s because every woman and every cancer is different. But, in general, women with early-stage breast cancer need 2 types of treatment. They need treatment directly to the breast, which is called “local treatment,” and they need treatment to the whole body, which is called “systemic treatment.” Local treatment is surgery and radiation. Systemic treatment is chemotherapy, hormone therapy, or both.
For surgery, women can often choose between these 2 options:

  • Mastectomy
    Surgery to remove the whole breast. Most women who have a mastectomy can also have surgery to reconstruct the breast that is removed.
  • Breast-conserving therapy (also called “lumpectomy”)
    Surgery to remove the cancer and a section of healthy tissue around it (called a “margin”). Women who choose this option keep their breast. But they usually must have radiation therapy after surgery to kill any cancer cells that might still be in the breast area.
    At the same time as they have lumpectomy or mastectomy, most women also have surgery to remove lymph nodes under the arm. Lymph nodes are pea-shaped organs that filter and trap cancer cells (figure 1). Depending on what kind of cancer a woman has and how far it has spread, she might also need systemic treatment with medicines that can slow or prevent the growth of cancer. This article will focus on the choice of surgery a woman has, not on systemic treatments or on lymph node surgery.

Will my choice of surgery affect how long I live?

No. Studies show that women who choose lumpectomy live just as long as those who choose mastectomy.

Will my choice of surgery affect the chances that cancer will come back?

Yes. Women who choose lumpectomy have a slightly higher chance of having their cancer come back. But if cancer comes back, it can usually be treated successfully.

Is lumpectomy always an option?

No. Lumpectomy is not an option for some women. For example, lumpectomy is sometimes not an option for women who:

  • Have more than 1 tumor in different areas of the same breast
  • Have cancer that has spread throughout the breast tissue and the surgeon can’t get all the cancer out with a margin of normal tissue around it.
  • Cannot have radiation therapy, for example because they are pregnant or have certain forms of skin cancer
  • Already had radiation to the area. (Radiation can only be given to an area of the body once.

How do I decide between the 2 surgery options?

— First, make sure you understand all the facts about the different treatment options.. Ask your doctor any questions you might have. Then think about how you feel about these issues:

  • The way you will look — Is it important to you to keep your own breast? How would you feel if your chest was flat and you had to wear a plastic breast in your bra? Ask to see pictures of women who have had the different kinds of surgery. Remember, women who choose mastectomy can have their breast reconstructed if they want.
  • The risk that cancer will come back — Women who choose lumpectomy live just as long as women who choose mastectomy. But women who choose lumpectomy have a slightly higher risk of cancer returning in the breast. Women whose cancer comes back after lumpectomy go on to have a mastectomy.
  • The time involved and the side effects of radiation — After lumpectomy, most women must have radiation therapy. This usually involves getting treatments 5 days a week for 3 to 6 weeks, depending on the woman’s age and other factors. This type of radiation will not make you sick or make your hair fall out. But it will tan and possibly even burn the skin on your chest. This burn is like a sunburn and goes away fairly quickly. Toward the end of treatment, radiation can make you feel a little tired, but this is not very common and usually doesn’t last long.
  • Recovery from surgery
    • Women who have lumpectomy go home from the hospital the same day as their surgery. For a week or 2 after surgery, they must rest and avoid sports, swimming and heavy lifting.
    • Women who have mastectomy stay in the hospital for 1 to 2 days after surgery. If they also have breast reconstruction, they might stay a day or 2 longer. They go home with drains that must be emptied twice a day. After about 2 weeks, the surgeon takes the drains out in the office. If more fluid or blood builds up after the drains come out, the doctor will drain it with a needle in the office. During the draining process and for a few weeks more, women who have a mastectomy must rest and avoid sports, swimming, or heavy lifting. Even after they recover, women who have mastectomy will not have normal feeling in the chest. Women who have mastectomy can have the breast that was removed reconstructed right away or later.
    • Regardless of which surgery you have, you will probably need to have biopsies of your lymph nodes. This part of the surgery usually does not cause problems. But in some cases it can cause arm swelling, pain, or stiffness; shoulder pain or stiffness; or a nerve injury. If any of these happen to you, you might need to do special exercises or have physical therapy (work with an exercise expert) to get back to normal.

How do I work with my doctor to make a decision?

Tell your doctor how you feel about the different treatment options. If there is something specific that worries you, tell your doctor about that, too. Then listen to what your doctor has to say about his or her experiences with women who had situations similar to yours. Together you can decide which treatment option is right for you. When you choose your treatment, you can find out more details about that option.

What is breast reconstruction?

Breast reconstruction is surgery to rebuild a breast that was removed to treat or prevent cancer. Reconstruction can be done using man-made materials, called implants, or using tissue taken from other parts of your body, called “flaps.”
If you are planning to have surgery to remove a breast, called a mastectomy, talk to your surgeon about reconstruction before you have the mastectomy. Your mastectomy might need to be done in a certain way for you to be able to have the type of reconstruction you want.

Do I need breast reconstruction after mastectomy?

No, you do not need it. The decision to have reconstruction is totally up to you. Some women feel better about themselves or feel like they look more normal if they have reconstruction after mastectomy. Other women do not mind having only 1 breast. The important thing is that you have a choice about what to do.

What if I decide not to have reconstruction?

If you decide not to have reconstruction, the side of your chest that had surgery will be flat and have a scar on it. If you want, you can wear a special bra with a pocket for a soft plastic breast. That way you’ll look more even, and your clothes will probably fit better.

When can I have my breast reconstructed?

Breast reconstruction can be done at the time of mastectomy or later. The timing for you will depend on the stage of your cancer and what other treatments you need.
Women with early-stage cancer or who are having mastectomies to prevent cancer can have the reconstruction at the same time as their mastectomy. This is called “immediate reconstruction.” Women who are having immediate reconstruction can have a “skin-sparing” mastectomy, which removes the breast tissue, but leaves as much of the healthy skin as possible. The skin that is left can then be used like a pocket to hold the tissue that will make up the new breast.
Women with later-stage cancer sometimes need to have radiation after mastectomy. (Radiation is a treatment that kills cancer cells.) These women need to delay reconstruction until the radiation treatment is finished. This is called “delayed reconstruction.” The delay is needed because the reconstructed breast could keep the radiation from reaching the right areas. Plus, radiation could damage the reconstructed breast.

What are the different ways that surgeons can reconstruct a breast?

The 2 main ways are with implants or with flaps. Plus, there are several kinds of flaps, each named for the muscles they are made of. The best reconstruction approach for you will depend on:

  • How big your breasts are to begin with
  • How much extra body fat you have and where
  • Whether you smoke, are overweight, or have health problems, such as diabetes, or heart or lung disease
  • Whether you have had surgery before and on what part of your body, because scars might affect which tissue can be used

How does reconstruction with an implant work?

A breast implant is basically a breast-shaped container that is filled with salt-water (called “saline”) or something that feels like Jell-O (called “silicone”). The implant is inserted under a layer of muscle in the chest.
Getting an implant usually involves 2 steps. First, the surgeon inserts a device called an “expander.” This device stretches the skin and muscle in the chest, so that they can hold the implant. Doctors gradually add more and more fluid to the expander until the skin and muscle are stretched enough for the implant. Then, the surgeon does another surgery to insert the implant .Implants are best for women with smaller breasts that don’t droop.

How does reconstruction with a flap work?

That depends on which type of flap is used. The most commonly used flaps are:

  • TRAM flaps — A TRAM flap is taken from the belly and is made up of skin, fat, and muscle. When the muscle in the flap stays attached to the blood vessels that supply it, it is called a “pedicled TRAM flap”. This type of flap is tunneled under the skin from the tummy to the new breast pocket.
    When the flap is completely disconnected from the belly and its blood vessels, it is called a “free TRAM flap”. This type of flap is attached to a new set of blood vessels in the chest. It doesn’t stay connected, so it does not have to be tunneled to its new location.
  • Both kinds of TRAM flaps can be done only in women who have enough belly fat to make a flap. After surgery, the belly looks flatter, like it does after a “tummy tuck.” Women who have this type of flap have a scar along their bikini line from hip to hip.
  • Lat flap — A Lat flap is taken from the back and is made up of skin, fat, and muscle. The flap stays attached to its own blood supply and is tunneled under the skin from the back to the chest. Women who have this kind of flap have a scar on their back beneath the bra line. They also often also get an implant, because there is not enough fat on the back to make a new breast.
  • DIEP flap — A DIEP flap is taken from the belly, but it is different from a TRAM flap because it is made up of skin and fat but NOT muscle. Connecting these flaps to a good blood supply is harder than it is for other flaps. That means the surgery can be more complicated and take longer.
  • Flaps taken from other places — Women who do not have enough belly fat to make good TRAM or DIEP flaps can have flaps taken from other parts of their body. For instance, doctors sometimes take flaps from the rear end or inner thigh.

Will my nipple be reconstructed?

If you want it to be, yes. Nipple reconstruction is usually done a few months after the breast construction is done. To make a new nipple, the surgeon can rearrange the tissue that is already there or use tissue from another part of the body. Surgeons also sometimes tattoo the nipple and the area around the nipple to make it the right color.

Will my new breast match my other breast?

As much as possible, yes. But the new breast will never be like the one you had before or like the other breast. Plus, you won’t have normal feeling (sensation) in the new breast. Your surgeon might need to operate on your healthy breast to make the 2 breasts look as similar as possible.

Can I choose which kind of reconstruction to have?

Yes and no. Only some of the reconstruction types will be appropriate for you. But if you think you would rather have 1 type of reconstruction over another, ask your surgeon if that approach would work for you. He or she can tell you if your choice makes sense, and if not, why not.

What is breast cancer screening?

Breast cancer screening is a way in which doctors check the breasts for early signs of cancer in women who have no symptoms of breast cancer. The main test used to screen for breast cancer is a special kind of X-ray called a mammogram. This is usually combined with regular breast exams done by the doctor or nurse.
The goal of breast cancer screening is to find cancer early, before it has a chance to grow, spread, or cause problems. Studies show that being screened for breast cancer lowers the chance that a woman will die of the disease.

Who should be screened for breast cancer?

Experts recommend screening for most women age 50 to 70, and for some older women who are healthy. (Screening should involve mammograms, as well as breast exams done by a doctor or nurse.) Some women age 40 to 49 should also be screened. For instance, women who are at high risk of breast cancer sometimes need to begin screening at a young age. This might include women who:

  • Carry genes that increase their risk of breast cancer, such as the “BRCA” genes
  • Have close relatives who got breast cancer at a young age

You should talk with your doctor or nurse to decide when you should start screening.

What are the benefits of being screened for breast cancer?

The main benefit of screening is that it helps doctors find cancer early, when it is easier to treat. This lowers the chances of dying of breast cancer.

What are the drawbacks to being screened for breast cancer?

The drawbacks include:

  • False positives — Mammograms sometimes give “false positives,” meaning they suggest a woman might have cancer when she does not. This can lead to unneeded worry and to more tests—including a biopsy in some cases, which can be painful. False positive results are more likely to happen in women younger than 50 than they are in older women.
  • Radiation exposure — Like all X-rays, mammograms expose you to some radiation. But studies show that the number of lives saved by catching cancer early greatly outweighs the very small risks that come from radiation exposure.

What happens during a mammogram?

Before the mammogram, you will need to undress from the waist up and put on a hospital gown. Then your breasts will be X-rayed 1 at a time. Each breast is X-rayed twice. Each is X-rayed once from the top down and once from side-to-side so that the radiologist can get a good look at all the tissue. To make the breast tissue easier to see, a nurse or technician will flatten each breast between 2 panels. This can be uncomfortable, but it lasts only a few seconds. If possible, avoid scheduling your mammogram just before or during your period. Breasts are extra sensitive at that time. Also, do not use underarm deodorant or powder on the day of your appointment.

What happens after a mammogram?

If a radiologist (the doctor who will look at your X-ray) is able to look at your mammogram right away, you might get the results the same day. If not, you should get a phone call or letter with your results within 30 days. If you do not hear back about your results, call your doctor or nurse’s office. Do not assume that your mammogram was normal if you hear nothing.

What if my mammogram is abnormal?

If your mammogram is abnormal, don’t panic. Nine out of 10 women with an abnormal mammogram turn out NOT to have breast cancer. You will need more tests to find out what’s really going on.
If your doctor thinks your abnormal result is probably NOT due to cancer, he or she might suggest that you wait and have another mammogram in 6 months. If your doctor thinks the abnormal result might be due to cancer, he or she will probably send you for more tests. Other tests could include a more detailed mammogram, called a diagnostic mammogram, or an ultrasound of the breast.
If the other tests still show any suspicious findings, your doctor or nurse will probably order a biopsy. During a biopsy, a doctor takes samples of breast tissue and sends them to the lab to be checked for cancer. Biopsies are usually done by taking some tissue from the breast with a needle during a mammogram or ultrasound. But in some cases biopsies involve a small surgery.

What about breast exams?

Your doctor or nurse should do a breast exam on a regular basis as part of breast cancer screening. During the exam, the doctor or nurse will look at your breasts and then carefully feel both breasts and the area under both arms. He or she will look for lumps, nipple changes, or any changes in the tissue or skin that could signal cancer.
Some women also like to do exams on their own breasts. No study has shown that breast self-exams lower the risk of dying from breast cancer, and most experts do not encourage self exams. Still, if you decide to do breast self-exams, make sure you know how to do them the right way (table 1).

Can I have a breast MRI instead of a mammogram?

Women are hearing a lot about breast MRIs in the news. But breast MRIs are not for everyone. Compared with mammograms, breast MRIs give more “false positives” and sometimes lead to unneeded biopsies. Still, breast MRIs are sometimes used to help find breast cancer in young women who have a high risk of breast cancer. Doctors do not recommend breast MRI to screen for breast cancer in women who do not have a high risk of breast cancer. In any case, MRIs don’t replace mammograms. They are used with mammograms for the high-risk women who need them.

How often should I have a mammogram?

Women who choose to start breast cancer screening at age 40 are usually screened once a year until age 50. After age 50, most experts recommend that screening be done every 1 to 2 years, depending on the woman’s risk of breast cancer.
Routine screening (with mammograms and breast exams) should continue as long as the woman is otherwise healthy.