Breast Cancer
Breast cancer overview
It is estimated that more than 210,000 women in the U.S. will be diagnosed
with breast cancer in 2003. It is now possible to detect most breast cancers
at a very early state. With early detection and improved treatments, more
women are surviving breast cancer. Today, women have more treatment options
than ever before.
See the Mammography page for more information about early detection.
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What are my treatment options?
Treatment options overview
Treatment options include mastectomy or breast conservation therapy
(BCT). Mastectomy is an operation to remove the entire breast, including
the nipple and glands under the arms called axillary nodes. Mastectomy
usually requires a hospital stay. Women who undergo a mastectomy have
the option of breast reconstruction.
Breast-conservation surgery removes
the breast tumor and a margin of surrounding normal tissues.
It is also known by other names: lumpectomy, partial mastectomy,
segmental mastectomy, and quadrantectomy. Radiation therapy follows
lumpectomy to eliminate any microscopic cancer cells in the remaining
breast tissue. The purpose of breast conservation therapy is
to give women the same cure rate they would have if they were treated
with a mastectomy, but to leave the breast intact, with an appearance
and texture as close as possible to what they had before treatment.
The surgeon may remove the lymph nodes at the same time as the lumpectomy
procedure or later. It is estimated that 75 to 80 percent of
patients can be treated with breast conservation therapy, rather than
mastectomy, with excellent results. Years of clinical study have proven
that breast conservation therapy offers the same cure rate as mastectomy.
Your
radiation therapy procedure might include:
- External Beam Therapy
- Intensity-Modulated Radiation Therapy
- Interstitial Therapy (or "Brachytherapy") - the temporary placement
of radioactive materials within the breast, usually employed to give an
extra dose of radiation to the area of the excision site (called a "boost").
Patients may also have chemotherapy or hormonal therapy if there is
a risk that the cancer may have spread outside of the breast to other
body organs.
How can I make a decision between mastectomy and breast conservation therapy?
Breast conservation therapy is used for patients with early stage invasive
breast cancers (called Stage I and Stage II in the classification system).
It is also used for patients with ductal carcinoma in situ (DCIS, called
Stage 0). Some of the reasons to not have breast conservation therapy include:
personal preference; increased risk of complications from radiation therapy
in individuals with certain rare medical conditions; and tumors that are
more likely than average to have a relapse in a breast with breast conservation
therapy.
Most patients can choose a treatment based on other factors, such as convenience
(for example, how far you must travel to receive radiation therapy) or
personal preference (feeling safer if you undergo a mastectomy, or being
very worried about the possible side effects from radiation therapy). Most
women prefer to keep their breast if this is possible to do safely, but
there is no right answer for everyone. However, this decision is not one
the physician can make for you.
Nearly all physicians will recommend patients be treated with mastectomy
instead of breast conservation therapy when the risk of recurrence in the
breast is more than 20 percent. This is the case for only a small number
of women, however.
Is radiation therapy necessary if the margins of the removed tissue are
negative?
Many studies have reviewed this approach for patients with invasive cancers.
Nearly all show the risk of relapse in the breast is much higher than when
radiation is not used (20 to 40 percent) than when it is (five to 10 percent).
Having breast cancer reappear in this way is a very traumatic event psychologically.
Also, patients may need to have a mastectomy to be cured in this situation,
so in more cases they may lose the breast than if they had undergone radiation
therapy initially. Finally, not everyone who has a recurrence in the breast
can be cured. Therefore, radiation therapy after lumpectomy is the standard
treatment around the world.
For patients with noninvasive cancer (known as "ductal carcinoma in
situ"), matters are more complicated. Lumpectomy without radiation
works well for many patients. However, there is disagreement on who can
be treated safely with just a lumpectomy. This should be discussed in detail
with your doctor.
What are the cosmetic results of breast conservation therapy?
Eighty to 90 percent of women treated with modern surgery and radiotherapy
techniques have excellent or good cosmetic results; that is, little or
no change in the treated breast in size, shape, texture, or appearance
compared to what it was like before treatment.
Patients with large breasts seem to have greater shrinkage of the breast
after radiation therapy than do smaller-breasted patients. However, this
problem now usually can be overcome by the use of higher x-ray energies.
What is the prognosis after recurrence?
Many patients with a recurrence of breast cancer can be successfully treated,
often with methods other than radiation, if radiation was used in the initial
treatment. For patients treated initially for invasive breast cancer, five
to 10 percent will be found to have distant metastases at the time of discovery
of the breast recurrence. The same proportion will have recurrences that
are too extensive to be operated on. These patients are rarely, if ever,
cured. Five-year cure rates for patients with relapse after breast conservation
therapy are approximately 60 to 75 percent if the relapse is confined to
the breast and a mastectomy is then performed.
For patients treated initially for ductal carcinoma in situ (DCIS), about
one-half of recurrences are invasive and one-half noninvasive DCIS. Cure
rates following recurrence after initial breast conservation therapy have
been high (90 to 100 percent) in some studies, but are not always perfect.
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What happens during radiation therapy?
Radiation is a special kind of energy carried by waves or a stream of particles.
When radiation is used at high doses (many times those used for x-ray imaging
exams), it can destroy abnormal cells that cause cancer and other illnesses.
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What are possible side effects of radiation therapy?
There are no immediate side effects from each radiation treatment given
to the breast. Patients do not develop nausea or hair loss on the head.
Most patients develop mild fatigue that builds up gradually over the course
of therapy. This slowly goes away between one and two months following
the radiation therapy. Most develop dull aches or sharp shooting pains
in the breast that may last for a few seconds or minutes. It is rare for
patients to need any medication for this. The most common side effect needing
attention is skin reaction. Most patients develop reddening, dryness and
itching of the skin after a few weeks. Some patients develop substantial
irritation.
Skin care recommendations include:
- Keeping the skin clean and dry using warm water and gentle soap
- Avoiding extreme temperatures while bathing
- Avoiding trauma to skin and sun exposure (use a sunscreen
with at least SPF 15)
- Avoiding shaving in the treatment field with a razor
blade (use an electric razor, if necessary)
- Avoiding use of perfumes, cosmetics, after-shave
or deodorants in the treatment field (use cornstarch,
with or without baking soda, in place of deodorants)
- Using only recommended unscented creams or
lotions after daily treatment.
Some patients develop a sunburn-like reaction, with blistering and peeling
of the skin, called "moist desquamation." This usually occurs
in the fold under the breast or in the fold between the breast and the
arm, or sometimes in the area given a radiation boost. Most people with
a limited area of moist desquamation can continue treatment without interruption.
When treatment must be interrupted, the skin usually heals enough to allow
radiation to be resumed in five to seven days. Skin reactions usually heal
completely within a few weeks of completing radiotherapy.
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What are some of the possible risks or complications?
Minor complications include:
- Slight swelling of the breast during radiotherapy. This usually goes
away within six to 12 months.
- The skin becomes darker during the course of radiotherapy,
similar to tanning from the sun. In most cases, this
also fades gradually over six to 12 months.
- Most women will have aches or pains from time to time in
the treated breast or the muscles surrounding the breast,
even years after treatment. The reason why this happens is not clear;
however, these pains are harmless, although annoying.
They are NOT a sign that the cancer is reappearing.
- Rarely, patients may develop a rib fracture years following
treatment. This occurs in less than one percent of patients
treated by modern approaches. These heal slowly by themselves.
More serious complications include:
- Very rarely, patients develop a breakdown of the skin, fractures of
the sternum (breastbone), or such severe pain in the breast that
surgery is needed for treatment.
- Radiation therapy given to the axillary lymph nodes can
increase the risk of patients developing arm swelling
("lymphedema")
following axillary (armpit) dissection. Radiation to this area
can cause numbness, tingling, or even pain and loss of strength
in the hand and arm years after treatment. Fortunately, both these
treatment effects are very rare.
- Some patients develop "radiation pneumonitis" from three
to nine months after completing treatment, which is a lung reaction
that causes a cough, shortness of breath and fevers. Fortunately,
it is usually mild enough that no specific treatment is needed, and
it goes away within two to four weeks with no long-term complications.
- Radiotherapy may damage the heart. Fortunately, radiation
techniques used now treat much less of the heart than
those used in the past. Current studies have found no
increased risk of serious heart disease in patients treated with
modern techniques even 10 to 20 years after radiotherapy
treatment was given. However, there is still some uncertainty about
the risks of radiation causing heart disease for individuals
who smoke or have preexisting heart disease, or for those
who receive certain chemotherapy drugs. It is likely
that such risks will be found to be very small also.
- Women age 45 or younger at the time of treatment may
have a slightly increased risk (a few percent at
most) of developing cancer of the other breast with time,
compared to the risk they would have if they did not undergo
radiation. There is a very small risk (perhaps 1 in 1,000
individuals) that cancers may develop five, 10, 20 or more years
later in the skin, muscle, bone, or lung directly in
the area of treatment.
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What kind of treatment follow-up should I expect?
The major goal of follow-up is, if possible, to detect and treat recurrences
in the irradiated breast or lymph nodes and new cancers developing later
in either breast before they can spread to other parts of the body. The
routine use of bone scans, chest x-rays, blood tests, and other tests to
detect the possible spread to other organs in patients without symptoms
does not appear to be useful. Your physician will determine a follow-up
schedule for you. This may include a physical exam every few months for
the first several years after treatment, and then every six to 12 months
or so after that. Annual follow-up mammograms are an important part of
your care. If symptoms or clinical circumstances suggest a recurrence,
diagnostic tests such as blood tests, ultrasound, computed tomography (CT),
magnetic resonance imaging (MRI), chest x-ray (CXR), or bone scan may be
needed.
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Are there any new developments in treating my disease?
Clinical Trials - To learn about current clinical trials
being conducted, see the Clinical
Trials page of the National Cancer Institute's Web site.
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