Cancer Support Group

Introduction
Treatment of breast cancer depends on how advanced the cancer is, the age of the patient, and her health. In most cases breast cancer is treated surgically, followed usually by some combination of radiation therapy, chemotherapy, or hormone therapy.

The standard surgical procedure for breast cancer was once radical mastectomy – total removal of the breast and the surrounding fat, muscle, and lymph nodes. However this has fallen out of favor now and is done in only very rare cases.

For many women whose breast cancer is detected early and is still localized, lumpectomy – removal of the cancerous lump and the lymph nodes under the arm – is now the preferred treatment. Followed by appropriate radiation therapy, chemotherapy, and hormone therapy, lumpectomy has proved as effective as radical mastectomy for early breast cancer and is much less disfiguring.

In cases where the tumor is more than 1.1 cm in size, modified selective mastectomy is advocated. In this procedure, the tumor and surrounding breast tissue are removed, but most of the muscle on the chest wall is left intact – which is less disfiguring than radical mastectomy.

Treatment
Treatment for breast cancer almost always begins with a decision about the type of surgery. The options are mastectomy, (removing the entire affected breast), or lumpectomy (removing just the malignant lump and a margin of healthy tissue around all edges of the tumor), followed by radiation therapy to destroy any remaining cancer cells. Today, the vast majority of women can save their breasts. Clinical research has proven that there is no difference in long–term survival between mastectomy or breast–conservation (lumpectomy) surgery.

Lumpectomy
Lumpectomy: A woman is considered a good candidate for lumpectomy if her tumor is less than two inches in size. Using that as a criteria, about 80% of all women with breast cancer qualify. However, there are other considerations: Cosmetic results may not be good in women who have relatively large lumps in small breasts. If there is more than one lump, the breast may not look normal after the removal of lumps and surrounding margins of healthy tissue. Women with very large breasts may not be good candidates for lumpectomy because they would require unacceptably high doses of radiation after surgery. Women who are unwilling or unable to have the follow–up radiation treatments are not good candidates for lumpectomy. Radiation is typically given five days a week for six to eight weeks after surgery. Patients who live far from a hospital or medical center that provides radiation therapy may find it inconvenient or impossible to travel back and forth for daily treatment. Women who are very young (20s and early 30s) may not be good candidates for breast conservation due to the higher risk of recurrence.

Mastectomy
A mastectomy usually involves removing the breast and some underarm lymph nodes. The nodes are examined by a pathologist for evidence that cancer has spread beyond the breast. Women who choose mastectomy usually can have breast reconstruction at the same time as surgery. Without reconstruction, mastectomy takes from one to two hours. Reconstruction adds another 30 minutes to eight hours of surgery time, depending on the type of procedure. It’s important to consult a plastic surgeon before surgery, this consultation can help women make a better decision on whether to have the reconstruction done immediately (during the surgery) or to postpone it. Although more mastectomies without simultaneous reconstruction are being done on an outpatient basis, most women are hospitalized for four to five days and may have to stay longer if they have had reconstruction. After surgery, most women need to do special exercises to overcome stiffness and regain mobility in the arm on the side of the mastectomy. The latest variation is a skin–sparing mastectomy in which the breast tissue is removed through a circular incision around the nipple. The skin thus remains intact so that the breast can be immediately reconstructed by inserting an implant or fatty tissue taken from the abdomen, back or buttocks. With a skin–sparing mastectomy, a separate incision is needed to remove underarm lymph nodes. This new procedure is not yet widely available, but proponents predict that it will soon become an option nationwide. Meanwhile, women interested in the skin–sparing procedure should contact their nearest cancer center.

Removing Lymph Nodes: Most breast cancer surgery also involves a procedure called axillary dissection–the removal of a wedge of fat from the underarm that usually contains between 10 and 15 lymph nodes. Microscopic examination of the nodes can suggest whether or not the cancer has spread beyond the breast. The need for additional treatment after surgery depends on whether or not some nodes are positive for cancer.

The lymph nodes can be removed in the course of a mastectomy. With lumpectomy, a separate incision is usually made to remove the wedge of fat that contains the nodes. Either way, most patients wake up from surgery to find a drain emerging from the underarm area to remove any fluid that accumulates. Several potential complications are associated with lymph node removal. The most serious is lymphedema, a swelling in the arm caused by an accumulation of fluid that doesn’t drain properly. The swelling can range from barely noticeable to an obvious enlargement of the arm. It can be either painless or painful. Although rare, lymphedema can be triggered by an infection, or it may occur from unknown causes. Some women develop it right away, and it may only last a short while then permanently resolve itself, others may develop some time later and have chronic problems with it. There are special exercises that can be done to help prevent the occurrence of lymphedema and special precautions that should be followed after lymph node removal. Examples are to wear gloves whenever gardening, to avoid constricting clothing and jewelry, and to shave underarms with an electric razor. There are also special treatments to help control lymphedema.

Staging
After surgery, the pathology report will provide information for staging the cancer, a process that helps to determine whether any further treatment is needed after surgery and to predict the outlook for a cure. Here’s a summary of the stages of breast cancer:

Stage I
Carcinoma in situ (DCIS).

Stage II
The tumor is two centimeters or less, no lymph node involvement, no evidence of cancer spread to distant sites in the body.

Stage III
Tumors less than five centimeters with no positive nodes, or distant spread, or tumors less than two centimeters with spread to moveable lymph nodes but no distant spread.

Stage IV
Tumor less than two centimeters with spread to “Fixed” lymph nodes but no distant spread.

Stage V
Any size tumor, any number of nodes involved, evidence of distant spread. The lower the stage, the better the outlook for survival.

Radiation
Radiation therapy (sometimes called radiotherapy) is almost always recommended after lumpectomy to destroy any cancer cells left behind and to prevent local recurrences in the breast. Without radiation therapy, the odds of a local recurrence increase by about 25%. These recurrences may predict cancer spread to other parts of the body, especially when they occur within the first three years after surgery. Physicians who administer radiation therapy are called radiation oncologists. There is no risk of being radioactive or losing your hair due to radiation treatments. However, radiation can cause side effects such as fatigue for a few weeks during the end of treatment and after treatment. Reddening, darkening and thickening of the breast may also occur and last for weeks or longer.

Chemotherapy
Chemotherapy: After surgery, some patients need chemotherapy, a course of powerful anticancer drugs that destroy cancer cells by interfering with their ability to reproduce. The need for chemotherapy depends on the stage of cancer and an assessment of all the other risk factors described in the pathology report. In some cases, chemotherapy may be recommended before treatment in order to shrink a large tumor so that it can be more easily removed. Chemotherapy is almost always recommended if cancer recurs. If chemotherapy is necessary, treatment is typically given over a period of months. The drugs may be given by injection or in pill form. Treatment may be given once every three or four weeks to allow patients to recuperate during the intervening weeks. Most chemotherapy for breast cancer involves a combination of three drugs, but the specific combination depends on the individual case. More recently, women who are at high risk of recurrent disease despite surgery, radiation therapy and standard chemotherapy are treated with high doses of chemotherapy after bone marrow transplantation. The best known side effects of chemotherapy are nausea and hair loss. However, not all drug combinations used to treat breast cancer result in hair loss, and newer antinausea drugs can keep nausea and vomiting to a minimum. Chemotherapy can also cause fatigue. More serious risks include a low white blood cell count that makes patients vulnerable to infection. Chemotherapy can also stop the ovaries from functioning and bring on menopause. Sometimes menstrual periods resume after treatment. There is also a type of chemotherapy called hormonal chemotherapy. When breast cancer patient’s pathology report shows that the tumor tested estrogen–receptor positive, the patient may be a candidate for this special type of hormonal therapy. Most patients take this drug for a five–year period. It is orally prescribed and is taken daily. Treatment can reduce the recurrence rate by 20% to 30%. New research suggests that treatment with certain drugs should continue for five years after breast cancer surgery. Recent studies have shown that two years isn’t long enough and there is no added survival benefit after five years of treatment. Side effects include hot flashes and a small increase in the risk of uterine cancer.

If Cancer Recurs
If breast cancer recurs or spreads to other parts of the body, doctors may recommend more aggressive chemotherapy. The choice of drug combination depends on whether the metastases affect vital organs and whether patients are already being treated for other health problems. Treatment for advanced cancer may involve a transplant of bone marrow, the spongy material inside bones that produces blood cells. Bone marrow transplantation is a procedure in which some bone marrow is extracted from the patient before chemotherapy and then returned afterward to help regenerate bone marrow destroyed by the chemotherapy. This procedure is usually recommended only when other measures have failed. The treatment itself is risky: about 6% of all patients die as a result of the toxic effect of chemotherapy, and there is also a risk of permanent nerve damage. It is considered suitable only for women with metastatic or recurrent breast cancer or when biopsy results show that 10 or more lymph nodes are positive for cancer.

Prevention
There is hardly anything one can do about a family history of breast cancer or the age when one begins and stops menstruating. And most women don’t plan to have their children at an early age simply to lower their breast cancer risk. Although there are no guarantees, you can take some steps to help prevent breast cancer.

Exercise
Exercise Studies have shown that women who exercise at least four hours a week are less likely to develop breast cancer than less active women. Exercise may reduce estrogen production by burning calories and thereby reducing body fat.

Diet
Diet Most studies suggest that women who eat a low–fat diet and consume a variety of fruits and vegetables may decrease their risk of breast cancer.

Screening
Screening Early detection is often the key to controlling breast cancer, and women should undergo several types of screening: Mammograms can detect breast cancer two to five years before a tumor becomes large enough to be felt as a lump.

Breast Examination
Breast Self–Examination
All women older than 20 are encouraged to perform a breast self–examination each month to get to know how their breasts normally feel and be better equipped to detect any changes. Although most lumps are not cancerous, any changes should be reported to your doctor immediately.

Physician Breast Examination
In addition to a monthly self–exam, women between 20 and 39 are advised by the American Cancer Society to get a clinical breast examination in their doctor’s office every three years, those older than 40 should get these exams annually.

Post Treatment Problems with Breast Cancer
After Treatment
After the first course of treatment is completed, it is very important to continue with all scheduled follow–up appointments. During these appointments, your doctors will ask questions about any symptoms, perform a physical examination and order laboratory or imaging tests as needed to find recurrences or side effects. Patients should never hesitate to tell their doctors or other health care providers about any symptoms or side effects that concern them.

At first, follow–up physical exams are done every 3–4 months. The longer a woman has been free of cancer, the less often the exams are needed. After 5 years, they are done once a year. Yearly mammograms of the remaining breast and the breast treated by partial or selective mastectomy are needed. Women taking tamoxifen should have yearly pelvic examinations, because the drug can increase their risk of uterine cancer.

Other tests such as blood tumor marker studies, blood tests of liver function, bone scans, and chest X–rays are not usually needed unless symptoms or physical exam findings suggest recurrence. These and other tests may be done as part of evaluating new treatments by clinical trials.

If initial exams and tests suggest a recurrence, a chest X–ray, CT scan, bone scan, and a biopsy may be done. Depending on the location of a recurrent cancer, treatment may involve surgery, radiation therapy, hormonal therapy, or chemotherapy.

Checkup for Metastases
The physician will perform regular physical exams, with special attention to the breast(s), lymph nodes, liver and skin, and will order regular mammography. Other tests may include X–rays of the lungs, blood tests to check the liver and kidneys, or to monitor tumor markers in the blood (Tumor markers are substances found in the blood, which may be elevated in cancer patients). In addition, other special exams of the lungs, liver or bones, including bone scans may be done. A woman should discuss with her doctor what her follow–up schedule would be.

Removal of lymph nodes
Doctors remove the lymph nodes under the arm in order to determine the stage by biopsy as well as a part of the treatment for breast cancer. For breast cancer, removal of 5–10 lymph nodes is adequate as a staging procedure.

Lymph Edema
Lymph–edema is an accumulation of fluid that causes swelling of an extremity. Lymph–edema occurs after trauma to or removal of the lymph nodes.

Risk Factors
Anyone who has had either a selective mastectomy or modified radical mastectomy in combination with axillary lymph node dissection and, often, radiation therapy, is at risk of developing lymph–edema.

The onset of lymph–edema is often subtle and unpredictable. There is no good way to predict who will or will not develop lymph–edema. It can occur immediately after surgery, months or even years later. The potential for developing lymph–edema remains throughout a woman’s lifetime.

One of the first symptoms of lymph–edema may be a feeling of tightness around the arm or hand on the same side that was treated for breast cancer. Any swelling, tightness, or injury to the arm or hand should be reported promptly to your doctor or nurse. With proper education and care, lymph–edema can be avoided or controlled if it develops.

Causes of Lymph Edema
Only some causes of Lymph–edema are known. Mostly lymph–edema occurs when there has been damage to the vessels or nodes of the lymph system, such as from surgery or radiation.

Prevention of lymph Edema
The best treatment for lymph–edema is to prevent it from occurring in the first place. The following are suggestions to help prevent lymph–edema:

• Wear gloves while doing housework, gardening or other types of work that can result in even minor injures. A lesion or break in the skin will allow infectious bacteria to enter the tissue.
• NEVER allow an injection or blood drawing in the affected extremity. Injections and blood drawing will pierce the skin providing an entry for infections. Have blood pressure checked in the unaffected extremity. The inflated blood pressure cuff further limits lymphatic circulation and can collapse lymphatic vessels, permanently damaging the affected limb. If both arms are affected, blood pressures should be taken in the leg.
• Avoid heavy lifting with the affected arm. Do not carry heavy handbags with over–the–shoulder straps. Lifting puts a strain on the arm with poor circulation.
• Avoid vigorous, repetitive movements against resistance with the affected arm (rubbing, scrubbing, pushing or pulling). Physical exertion causes sudden, rapid blood flow through the muscle and tissue, further damaging an already compromised lymphatic system.
• Elevate the affected arm(s) when possible to improve circulation. Physical activity is encouraged, however, consult a physical therapist about any sports activities in which you participate, because some may aggravate the condition. Physical exertion forces the damaged lymphatic system to try to do work it cannot do.
• Avoid extreme hot or cold temperature changes such as hot tubs, saunas or sunbathing. At all times keep the limb protected from the sun. Heat increases blood flow through tissues. Sudden temperature changes cause undue stress on the weakened system.
• Maintain good hygiene by keeping skin clean and dry with hypo–allergenic soap or deodorant. This will protect skin from irritation and possible infection.
• Use an electric razor rather than a safety razor. An electric razor will prevent puncturing the skin and subsequent infections.
• Do not wear tight jewelry around affected fingers or arms. Constricting items will worsen an already compromised system.
• Avoid cutting cuticles when manicuring hands. Any skin puncture risks infection.
• Avoid pet scratches and insect bites. There is an increased risk of infection.
• Maintain your ideal body weight through a well balanced, low salt diet, avoid smoking and alcoholic beverages. Unwanted weight gain will increase swelling in the limbs.

Care to be taken at home after the surgery
After breast surgery, a regular routine of simple exercises will help to restore your mobility and reduce muscle stiffness. To minimize potential discomfort from radiation therapy, avoid wearing a bra or clothes that may irritate the area, keep your skin clean and airy, and use only those skin lotions, creams and deodorants recommended by your doctor.