The following information is provided by the
U.S. Department of Health and Human Service
The National Cancer Institute

The Breasts

The breasts are organs that produce milk. Each breast has 15 to 20 sections called lobes that are arranged like the petals of a daisy. Each lobe has many smaller lobules, which end in dozens of tiny milk-producing bulbs. The lobes, lobules, and bulbs are all linked by thin tubes called ducts. These ducts lead to the nipple in the center of a dark area of skin, called the areola. Fat fills the spaces between the other parts of the breast. Muscles cover the ribs and lie under the breast, but they are not part of the breast.

What is Cancer?

Cancer is a group of diseases. More than 100 different types of cancer are known - and there are several types of breast cancer. They all have one thing in common: abnormal cells grow and destroy body tissue.

Healthy cells that make up the body's tissues grow, divide, and replace themselves in an orderly way. This process keeps the body in good repair. Sometimes, however, some cells lose the ability to control their growth. They grow too rapidly and without any order. Too much tissue is made, and tumors are formed. Tumors can be benign or malignant.

• Benign tumors are not cancer. They do not spread to other parts of the body and are seldom a threat to life. Often, benign tumors can be removed surgically, and they are not likely to return.
• Malignant tumors are cancer. They can invade and destroy nearby healthy tissues and organs. Cancer cells can also break away from the tumor and enter the bloodstream or lymphatic system. That is how cancer can spread to other parts of the body. This spread is called metastasis. Even if cancer is removed from the breast, the disease sometimes returns because cancer cells already may have spread.

Early Detection

Women's breasts come in many sizes and shapes. And each woman's breasts change during her life because of age, the monthly menstrual cycle, pregnancy, menopause, or taking birth control pills or other hormones.

It is important to find breast cancer as early as possible. If cancer is found early, there are choices for treatment. With prompt treatment, the outlook is good. The National Cancer Institute encourages women to take an active role in early detection of breast cancer by:

• Practicing monthly breast self-examination (BSE);
• Having a yearly breast exam; and
• Getting a routine mammogram after age 40.

Women are often confused about what their breasts are supposed to feel like. It is normal for the breasts to feel lumpy and uneven. Sometimes the breasts are swollen and tender, especially right before a woman's menstrual period. By doing monthly BSE, women learn what is normal for their own breasts, and they are more likely to find anything unusual that might be a warning sign of cancer. Any changes should be reported to the doctor.

The second step of early detection is for a woman to have her breasts checked regularly by her doctor.

Mammograms (x-rays of the breast) can find many breast cancers before they can be felt. Mammography, together with a breast exam by a health professional, can reduce the number of deaths from breast cancer. Starting at age 40, a woman should have a mammogram every 1 to 2 years. When she reaches 60, she should have a mammogram every year. (Another NCI booklet, Breast Exams: What You Should Know, has more information about early detection.)

Symptoms

Breast cancer can cause many symptoms. Some warning signs to watch for include:

• A lump or thickening in the breast or under the arm;
• A change in the size or shape of the breast;
• Discharge from the nipple;
• A change in the color or feel of the skin or the breast or areola (such as dimpling, puckering, or scaliness).

Pain is usually not an early warning sign of breast cancer. However, a woman should see her doctor if she notices any changes in her breasts. Changes may be caused by cancer or by other less serious problems. Only a doctor can tell for sure.

Diagnosis

To diagnose breast cancer, a women's doctor does a careful physical exam and asks about her personal and family medical history. In additions to checking general signs of health (temperature, pulse, blood pressure, and son on), the doctor may do one or more of these exams:

• Palpation. By carefully feeling the breast, the doctor can tell a lot about a breast lump - its size, its texture, and whether it is removable.
• Aspiration. The doctor may use a thin needle to remove fluid or a small amount of tissue from a breast lump. This may show whether the lump is a fluid-filed cyst (not cancer) or a solid mass (which may or may not be cancer).
• Mammography. X-rays of the breast can give the doctor important information about a breast lump. Also, a mammogram can show tumors too small to be felt.

• Other tests. Sometimes the doctor orders other tests, called imaging techniques, along with mammography. However, at this time, these tests are not reliable enough to be used alone.

  Ultrasound is a test that sends high-frequency sound waves, which cannot be heard by humans, into the breast. The pattern of echoes is shown on a monitor, like a TV screen. This is sometimes called a sonogram. Thermography is a test that measures and record heat patterns in the breast. Diaphanography is an exam that is done by shining a bright light through the breast.

• Biopsy. A biopsy is surgery to take out part or all of a lump or suspicious area. The tissue is examined under a microscope by a pathologist. A biopsy is the only sure way to know whether cancer is present.

  A woman who is going to have a biopsy has an important choice to make She can decide that, if cancer is found, she will have the surgery at the same time as the biopsy (a one-step procedure_. Or, she can decide to have just a biopsy and, if it shows cancer, have treatment within the next few weeks (a two-step procedure). This short delay gives a woman time to find out about her treatment choices, to get a second opinion, and to prepare for her stay in the hospital Studies show that a brief delay between biopsy and treatment does not reduce the chances of a successful treatment. Many doctors and patients prefer the two-step procedure and it is the most common approach.

• Hormone receptor tests. If the biopsy shows that cancer is present, laboratory tests called estrogen and progesterone receptor tests are usually done on the cancer cells. These tests can tell whether hormones promote the growth of the cancer. This information helps the doctor decide whether hormone treatment is likely to be useful. Hormone receptor tests are done at the same time of biopsy because the tissue needed for the test may be hard to get later on.

  Four out of five breast lumps are not cancer. If a woman has a fluid-filed cyst, it most likely can be drained by fine needle aspiration. If the lump is a benign tumor, it can be removed by surgery with no further problems. Some lumps may not need any treatment, but the doctor may want to check the woman regularly.

  If the biopsy shows that the lump is cancer, other special laboratory tests may be done on the tissue to learn more about the cancer. Also, the woman will have other tests to find out whether the cancer has spread from the breast to other parts of her body. The doctor usually orders chest x-rays and blood tests. Because breast cancer may spread to the bones, liver, lungs, or brain, the doctor may also order special exams to check these areas.

  These tests help the doctor tell the extent, or stage, of the disease. Doctors use this staging system for breast cancer:

• Carcinoma in situ is very early breast cancer. Cancer is found in a local area and in only a few layers of cells.
• Stage 1 means the tumor is no larger than 2 centimeters (cm) - about an inch - and has not spread beyond the breast.
• Stage II means the tumor is from 2 to 5 cm - about 1 to 2 inches - and/or has spread to the lymph nodes under the arm.
• Stage III means the cancer is larger than 5 cm - about 2 inches. It involves more of the underarm lymph nodes, and/or it has spread to other lymph nodes or to other tissues near the breast.
• Stage IV means the cancer has spread to other organs of the body, most often the bones, liver, lungs, or brain.

Treatment

Treatment depends on the type of breast cancer and how far it has spread, as well as on a woman's age, menopausal status, and general health. The doctor will develop a treatment plan to fit a woman's individual needs.

Planning Treatment

Before starting treatment, a woman might want a second doctor to review her diagnosis and treatment plan. A short delay will not reduce the chances that her treatment will be successful. There are a number of ways to get a second opinion.

• The woman's doctor can discuss her case with other doctors who treat breast cancer.
• Patients can get the names of doctors from the local medical society, nearby hospitals or medical schools, or the Directory of Medical Specialists, a book available in many public libraries.
• The Cancer Information Service, at 1-800-4-CANCER, can answer questions about breast cancer and its treatment and also may be able to help patients locate doctors to consult for a second opinion.

Methods of Treatment

Breast cancer is treated with surgery, radiation therapy, chemotherapy, and hormone therapy. The doctor may use just one method or combine them depending on the patient's needs. In some cases, the patient may be referred to other doctors who specialize in the different kinds of cancer treatment.

Surgery is the most common treatment. The surgeon removes the tumor in the breast and, usually, the lymph nodes under the arm. The lymph nodes are removed because they filter the lymph that flows through the breast and other parts of the body, and they are one of the first places where breast cancer spreads. Cancer cells in the lymph nodes mean that there may be cancer elsewhere in the body.

Radiation therapy (also called radio-therapy) uses high-powered rays to damage cancer cells and stop them from growing. Like surgery, radiation therapy is a local treatment; it affects only the cells in the treated area. Radiation may come from an x-ray machine outside the body (external radiation). It can also come from radioactive materials placed directly in the breast through thin plastic tubes (implant radiation). Sometimes, both are used.

The patient goes to the hospital or clinic each day for external radiation treatments. Usually treatments are given 5 days a week for 5 to 6 weeks. At the end of that time, an extra "boost" of radiation is usually given to the tumor site. The boost may be either external or internal (using an implant). Patients usually stay in the hospital for a short time for implant radiation.

Chemotherapy uses drugs to kill cancer cells. The doctor may use just one drug or a combination. Chemotherapy may be given by mouth or by injection into a muscle or vein. The drugs enter the bloodstream and travel through the body. Chemotherapy is given in cycles: a treatment period followed by a rest period, then another treatment, and so on. This type of treatment is called systemic therapy.

Depending on which drugs are given, most patients have chemotherapy as an outpatient at the hospital, at the doctor's office, or at home. Sometimes the patient may need to stay in the hospital for a short while.

Hormone therapy is used to keep cancer cells from getting the hormones they need to grow. This treatment may include the use of drugs that change the way hormones work, or surgery that removes organs such as the ovaries that make hormones. Like chemotherapy, hormone therapy can act on cells all over the body.

Treatment Choices

Breast cancer is very treatable. The choice of treatment depends on the stage of the cancer (whether it is just in the breast or has spread to other places), the type of breast cancer, and certain characteristics of the cancer cells (such as how fast they are growing). The patient's age, menopausal status, and general health are also important. Decisions about treatment are also based on the experience of the doctor and the desires of the patient.

The different types of surgery used to treat breast cancer are:

• Modified radical mastectomy removes the breast, the lymph nodes under the arm, and the lining over the chest muscles (but leaves the muscles). This is the most common surgery for breast cancer.
• Lumpectomy removes just the breast lump and is followed by radiation therapy. Most surgeons also remove the lymph nodes under the arm.
• Total or simple mastectomy removes just the breast. Sometimes the underarm lymph nodes closest to the breast also are removed.
• Partial or segmental mastectomy removes the tumor, some of the normal breast tissue around it, and the lining over the chest muscle below the tumor. Usually some of the underarm lymph nodes are removed In most cases, radiation therapy follows the surgery.
• Radical mastectomy (also called the Halsted radical mastectomy) removes the breast, chest muscles, all of the lymph nodes under the arm, and some additional fat and skin. This operation was the standard for many years. It is still used on occasion but for most patients, less extensive surgery is just as effective.

Patients with carcinoma in situ (noninvasive breast cancer) may have a mastectomy or breast-sparing surgery. As with other breast cancers, the type of surgery is based on many factors. Also, depending on the specific type of breast cancer involved, the lymph nodes may be removed, and radiation therapy may be advised.

The treatment choices for early stage breast cancer (stage I and stage II) include limited surgery (such as lumpectomy or partial mastectomy) followed by radiation therapy, or a mastectomy. The lymph nodes under the arm are also removed The type of surgery depends on the size and location of the tumor, the type of cancer, the age and general health of the woman, and the size of her breast.

In addition, chemotherapy or hormone therapy should be considered after primary treatment for patients with early stage breast cancer this additional treatment is called adjuvant therapy. It is used to prevent a recurrence by killing undetected cells that may remain in the body. The choice between chemotherapy or hormone therapy depends on the patient's age, menopausal status, hormone receptor status, and other factors.

Until recently, women whose underarm lymph nodes are free of cancer usually received no additional treatment because they have a good chance of survival. But scientists know that cancer may return in about 30 percent of these women. For these women, adjuvant therapy may prevent or delay the cancer's return.

Women may also consider having plastic surgery to rebuild the breast after surgery.

Patients with stage III breast cancer usually have both local and systemic treatment. The local treatment may be mastectomy and/or radiation therapy. Chemotherapy and/or hormone therapy are also used.

Women who have stage IV breast cancer receive chemotherapy and/or hormone therapy. They may also have limited surgery or radiation therapy to control the tumor in the breast. Radiation may also be useful to treat breast cancer that has spread to specific parts of the body.

If breast cancer returns, treatments depends on the location and extent of the recurrent cancer, the patient's menopausal status and general health, and her response to her initial therapy. If the disease reappears in the breast area, treatment usually is surgery or radiation. Also, some type of systemic therapy is recommended. If the disease develops in other parts of the body, patients are likely to have chemotherapy and/or hormone therapy; some patients also may be helped by radiation therapy or surgery.

Side Effects of Treatment

The methods used to teat breast cancer are very powerful. It is hard to limit the effects of cancer treatment so that only cancer cells are destroyed; normal, healthy tissue may also be damaged. That's why treatment often causes unpleasant side effects. Side effects depend on the type of treatment used and on the part of the body being treated.

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

Because nerves are cut during surgery, patients may have numbness and tingling in the chest, underarm, shoulder, and arm. These problems usually go away within a few weeks, but some numbness may be permanent.

Removing the lymph nodes under the arm slows the flow of lymph. In some women, lymph builds up in the arm and hand and causes swelling (lymphedema). Also, it is harder for the body to fight infection after the lymph nodes have been removed, and women need to protect the arm or hand on the treated side from injury - for the rest of t heir lives.

During radiation therapy, patients may become very tired as treatment continues. Resting as much as possible is important. Skin reactions in the breast area, such as redness or dryness, are common. Good skin care is important at this time. The patient should not use lotions or creams on the skin without the doctor's advice. Following radiation therapy, the treated breast may be firmer and somewhat larger or smaller than before.

The side effects of chemotherapy depend on the drugs that are given. In addition, each person reacts differently. Chemotherapy affects rapidly growing cells, such as blood-forming cells and those that line the digestive tract. As a result, the patient may have side effects such as a lower resistance to infection, less energy, loss of appetite, nausea, vomiting, or mouth sores She may also lose her hair. These are short-term side effects; they usually end after treatment stops. Women taking chemotherapy often have the symptoms of menopause (hot flashes, vaginal dryness, pain during intercourse, and irregular periods). Chemotherapy can also cause long-term side effects such as infertility.

Hormone therapy can cause a number of side effects, depending on the specific drug or surgical procedure, but they usually are not severe. When treatment interferes with the body's production or use of estrogen, the patient may have some of the symptoms of menopause, such as hot flashes, interrupted periods, and vaginal dryness.

Loss of appetite can be a serious problem for patients during therapy. Patients who eat well may be better able to withstand the side effects of their treatments. So good nutrition is an important part of the treatment plan. Eating well means getting enough calories to prevent weight loss and having enough protein to build and repair muscles, organs, skin, and hair. Many patients find that eating several small meals and snacks during the day works better than trying to have three large meals.

The side effects that patients have during cancer treatment vary for each person. They may even be different from one treatment to the next. Doctors try to plan treatment to keep problems to a minimum. Fortunately, most side effects are temporary, but for some patients the side effects can be permanent. Doctors, nurses, and dietitians can explain the side effects of cancer treatment and can suggest ways to deal with them.

Recovery from Treatment

Recovery from treatment is important for every breast cancer patient Recovery will be different for each woman, depending on the extent of the disease and the treatment she receives.

Exercising after surgery can help a woman regain motion and strength in her arm and shoulder It an also reduce pain and stiffness in her neck and back. Carefully planned exercises should be started as soon as the doctor says the woman is ready, often within a day or so after surgery. At first, exercises are gentle and can even be done in bed. Gradually, the exercise should become a part of the woman's normal activities. (Women who have a mastectomy and immediate breast reconstruction have different exercise needs that the doctor will explain.)

Lymphedema after surgery can be reduced or prevented with exercises and by resting with the arm propped up on a pillow. If lymphedema becomes a problem later on, the woman should tell her doctor, who may suggest other exercises. Some women with lymphedema wear an elastic sleeve or use an elastic cuff to improve lymph circulation. Other approaches - including mediation, a low-salt diet, or a machine that compresses the arm - may be suggested by the doctor.

After a mastectomy, some women choose to wear a breast form (prosthesis). Others have breast reconstruction. Each choice has its pros and cons, and what is right for one woman may not be right for another. What's important is that nearly all breast cancer patients have a choice It may be helpful to talk with a plastic surgeon before the mastectomy is done, but reconstruction is still possible years later.

Follow up Care

Regular follow up exams are very important after breast cancer. The doctor will continue to check the patient closely to be sure that the cancer has not returned. Check-ups, usually include exams of the chest, underarm, and neck. From time to time, the patient will have a complete physical exam, blood and urine tests, a mammogram, and other x-rays. The doctor sometimes orders scans (special x-rays) and other tests, too.

A woman who has had breast cancer should check both the treated area and her other breast each month. She should report any changes to her doctor right away. Also, she should tell her doctor about other physical problems if they come up, such as pain, loss of appetite or weight, changes in menstrual periods, unusual or lasting digestive problems, coughing or hoarseness, headaches, dizziness, or blurred vision. These problems may be a sign that the cancer has returned, but they can also be signs of many other problems. Only the doctor can tell for sure.

Adjusting to the Disease

The diagnosis of breast cancer can change a woman's life and the lives of those close to her. It's natural for the patient and her family and friends to have many different and sometimes confusing emotions.

Women and their loved ones may feel frightened, angry, or depressed. These are normal reactions that people have when faced with a serious health problem Others in the same situation have found that they cope with their emotions better if they can talk openly about their feelings with those who love them.

Concerns about what the future holds - as well as worries about tests, treatments, a hospital stay, and medical bills - are common. Talking with doctors, nurses, or other members of the health care team may help to calm fears and ease confusion. A woman can take an active part in decisions about her medical care by asking questions about breast cancer and her treatment choices. Patients, family members, and friends often find it helpful to write down questions to ask the doctor as they think of them Taking notes during visits to the doctor helps them remember what was said. Patients should ask the doctor to explain anything that is not clear.

Patients have many important questions, and the doctor is the best person to answer them. Most women ask about the extent of their cancer, how it can be treated, and how successful the treatment is likely to be. These are some other questions to ask the doctor:

• What are my treatment choices?
• What are the benefits of treatment?
• What are the risks and side effects of treatment?
• How will I look after treatment?
• Will I need to change my normal activities? For how long?
• Can I keep working during treatment?
• How often will I need to have checkups?

Sometimes women who have had breast cancer are worried, especially after surgery, that the changes to t heir bodies will affect not only how they look, but how other people feel about them. They may worry about holding a job, caring for their families, or starting new relationships. Concerns about sex can be upsetting, too.

Sharing these feelings with loved ones can help everyone feel more at ease, opening the way for others to show their concern and offer their support. Many patients feel that it helps to talk with others who are facing problems like theirs. Women can meet other breast cancer patients through self-help and support groups such as those described in the next section.

The doctor is the best person to give advice about treatment, working, or limiting daily activities. If it is hard to talk with the doctor about feelings or other very personal matters, it may be helpful to speak with a nurse, social worker, counselor, or member of the clergy.

Living with any serious illness can be difficult and challenging. The public library is a good source of books and articles on living with cancer.

Support for Breast Cancer Patients

Learning to live with the changes that are brought about by having breast cancer is easier for patients and those who love them when they have helpful information and support services. Often, a social worker at the hospital or clinic can suggest local and national groups that will help with rehabilitation, emotional support, financial aid, transportation, or home care.

The American Cancer society (ACS), for example, is a nonprofit organization that has many services for patients and their families. Their Reach to Recovery program offers special help for breast cancer patients. Trained volunteers, who have had breast cancer themselves, visit patients at the doctor's request and lend emotional support to women before and after treatment. They share their experiences with breast cancer treatment, rehabilitation, and breast reconstruction.

Another resource for women who have had breast cancer surgery is ENCORE. Sponsored by the YWCA, this program includes exercise to music, water exercises, and a discussion period. A woman may join a group the third week after surgery, with her doctor's permission.

Local ACS and YWCA offices are listed in the white pages of the telephone directory. The addresses and telephone numbers of the national headquarters of these organizations are found on page 30. Information about other programs and services for breast cancer patients and their families is available through the Cancer Information Service at 1-800-4-CANCER.

What the Future Holds

Each year, more than 142,000 American women will find out they have breast cancer. Because researchers are finding better ways to detect and treat breast cancer, the chances of recovery keep improving.

Doctors often talk about "surviving" cancer, or they may use the term "remission" rather than "cure". Even though many breast cancer patients recover completely, doctors use these terms because cancer can recur. It is normal for patients to be concerned about their futures. Sometimes patients use statistics they have heard to try to figure out their own chances of being cured. It is important to remember, however, that statistics are averages. They are based on the experiences of large numbers of patients, and no two cancer patients are alike. Only the doctor who takes care of the patient knows enough about her case to discuss her chance of recovery (prognosis).

The Promise of Cancer Research

Scientists at hospitals and medical centers all across the country are studying breast cancer. They are trying to learn what causes this disease and how to prevent it. And they are also looking for better ways to diagnose and treat it.

Causes and Prevention

Breast cancer is the second leading cause of cancer deaths among women in the United States (lung cancer is the first). About q1 woman in 10 will develop breast cancer at some time in her life. ) Breast cancer also affects about 900 men each year.)

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

Although scientists do not know exactly why breast cancer develops, they know some things increase a woman's chances of getting the disease:

• Age. About 75 percent of all breast cancers are found in women over the age of 60. The disease is uncommon in women under the age of 35 and quite rare under the age of 20.
• Family history: The risk of getting breast cancer doubles for a woman whose mother or sister has had the disease. If the mother's cancer began before menopause, her daughter's risk is somewhat higher.
• Personal history: Having cancer in one breast means that the risk of getting cancer in the other breast is about four to five times higher than the average. About 15 percent of women treated for cancer in one breast are likely to get cancer in the other breast later on.

Other risk factors include having the first menstrual period at an early age, having a late menopause, having the first child after the age of 30, and never having children.

Recent research suggests that a person's diet may affect the chances of getting some types of cancer. Breast cancer appears more likely to occur in women whose diet is high in fat Many scientists believe that avoiding a high-fat diet, eating well-balanced meals, and maintaining ideal weight can lower a woman's risk of cancer.

The ordinary lumpiness that many women have in their breasts (also called benign breast condition) does not increase the risk of breast cancer.

Detection

Scientists are trying to improve ways to find breast cancers when they are very small. For example, they are studying tumor markers, substances that may be present in abnormal amounts in the blood or urine of a person with breast cancer Several of these markers have been studies, and the research is continuing. At this time, however, no blood or urine test is reliable enough to detect early breast cancer.

Treatment

The NCI is supporting many studies of new treatments for breast cancer. When laboratory research shows that a new treatment method has promise, it is used to treat cancer patients in clinical trials. These trials are designed to answer scientific questions and to find out if a new treatment is both safe and effective. Patients who take part in clinical trials make an important contribution to medical science and may have the first chance to benefit from improved treatment methods.

A woman with breast cancer who is interested in taking part in a trial should discuss this option with her doctor.

Doctors can learn about clinical trials through PDQ (Physician Data Query), a computerized system of cancer treatment information developed by the NCI. It can give doctors the latest information on standard treatments and on studies being done around the country for most types of cancer. Doctors can use an office computer or the services of a medical library to get PDQ information. CIS offices also provide PDQ information and can tell doctors how to use PDQ on a regular basis. Patients and the public can also get PDQ information through the CIS.

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