Breast Cancer

What Is Breast Cancer?

Breast cancer is a malignant (cancerous) tumor that starts from cells of the breast. The disease occurs mostly in women, but men can get breast cancer too. The information here refers only to breast cancer in women.

A woman's breast is made up of glands that make breast milk (lobules), ducts (small tubes that carry milk from the lobules to the nipple), fatty and connective tissue, blood vessels, and lymph (pronounced limf) vessels. Most breast cancers begin in the cells that line the ducts (ductal cancer), some begin in the lobules (lobular cancer), and the rest in other tissues.

Lymph vessels are like veins, except that they carry lymph fluid instead of blood. Lymph is a clear fluid that contains immune system cells and waste products. Most lymph vessels lead to small, bean-shaped collections of tissue called lymph nodes. Most lymph vessels of the breast lead to lymph nodes under the arm. These are called axillary (ax-uh-lair-ee) nodes.

If breast cancer cells reach the underarm lymph nodes and continue to grow, they cause the nodes to swell. Once cancer cells have reached these nodes they are more likely to spread to other organs of the body as well.

Benign Breast Lumps

Most breast lumps are benign (be-nine); that is, they are not cancer. Benign breast tumors are abnormal growths, but they do not spread outside of the breast and they are not life threatening. But some benign breast lumps can increase a woman's risk of getting breast cancer.

Most lumps turn out to be caused by fibrocystic (fi-bro-sis-tik) changes. Cysts are fluid-filled sacs. Fibrosis is the formation of scar-like tissue. Such changes can cause breast swelling and pain. The breasts may feel lumpy, and sometimes there is a clear or slightly cloudy nipple discharge.

Main Types of Breast Cancer

Understanding key words as they relate to breast cancer can be a challenge. Here are the most common types of breast cancer:

Carcinoma in situ (in sigh-to): This term is used for early stage cancer, when it is confined to the place where it started. In breast cancer, it means that the cancer is confined to the ducts or the lobules, depending on where it started. It has not gone into the tissues in the breast nor spread to other organs in the body.

Ductal carcinoma in situ (DCIS): This is the most common type of noninvasive breast cancer. DCIS means that the cancer is confined to the ducts. It has not spread through the walls of the ducts into the tissue of the breast. Nearly all women with cancer at this stage can be cured. The best way to find DCIS early is with a mammogram.

Lobular carcinoma in situ (LCIS): This condition begins in the milk-making glands but does not go through the wall of the lobules. Although not a true cancer, having LCIS increases a woman's risk of getting cancer later. For this reason, it's important that women with LCIS to follow the screening guidelines for breast cancer..

Invasive (infiltrating) ductal carcinoma (IDC): This is the most common breast cancer. It starts in a milk passage or duct, breaks through the wall of the duct, and invades the tissue of the breast. From there it can spread to other parts of the body. It accounts for about 80% of invasive breast cancers.

Invasive (infiltrating) lobular carcinoma (ILC): This cancer starts in the milk glands or lobules. It can spread to other parts of the body. About 10% of invasive breast cancers are of this type. There are also several other less common types of breast cancer.

What Causes Breast Cancer?

We do not yet know exactly what causes breast cancer, but we do know that certain risk factors are linked to the disease. A risk factor is anything that increases a person's chance of getting a disease such as cancer. Different cancers have different risk factors. Some risk factors, such as smoking, can be controlled. Others, like a person's age or family history, can't be changed. But having a risk factor, or even several, doesn't mean that a person will get the disease.

Some women who have one or more risk factors never get breast cancer. And most women who do get breast cancer don't have any risk factors. While all women are at risk for breast cancer, the factors listed below can increase a woman's chances of having the disease.

Risk Factors You Cannot Change

Gender: Simply being a woman is the main risk for breast cancer. While men can also get the disease, it is about 100 times more common in women than in men.

Age: The chance of getting breast cancer goes up as a woman gets older. Nearly 8 out of 10 breast cancers are found in women age 50 or older.

Genetic risk factors: About 5% to 10% of breast cancers are linked to changes (mutations) in certain genes. The most common gene changes are those of the BRCA1 and BRCA2 genes. Women with these gene changes have up to an 80% chance of getting breast cancer during their lifetimes. Other gene changes may raise breast cancer risk as well.

Family history: Breast cancer risk is higher among women whose close blood relatives have this disease. The relatives can be from either the mother's or father's side of the family. Having a mother, sister, or daughter with breast cancer about doubles a woman's risk.

Personal history of breast cancer: A woman with cancer in one breast has a greater chance of getting a new cancer in the other breast or in another part of the same breast. This is different from the first cancer coming back (recurrence).

Race: White women are slightly more likely to get breast cancer than are African-American women. But African American women are more likely to die of this cancer. Many experts now believe that the main reason for this is because they have faster growing tumors. Asian, Hispanic, and American Indian women have a lower risk of getting breast cancer.

Abnormal breast biopsy: Certain types of abnormal biopsy results can be linked to a slightly higher risk of breast cancer.

Earlier breast radiation: Women who have had radiation treatment to the chest area (as treatment for another cancer) earlier in life have a greatly increased risk of breast cancer.

Menstrual periods: Women who began having periods early (before 12 years of age) or who went through the change of life (menopause) after the age of 55 have a slightly increased risk of breast cancer.

Treatment with DES: In the past, some pregnant women were given the drug DES (diethylstilbestrol) because it was thought to lower their chances of losing the baby. Recent studies have shown that these women (and their daughters who were exposed to DES while in the uterus), have a slightly increased risk of getting breast cancer.

Breast Cancer Risk and Lifestyles

Not having children: Women who have had not had children, or who had their first child after age 30, have a slightly higher risk of breast cancer. Being pregnant more than once and at an early age reduces breast cancer risk.

Birth control pills: It is still not clear what part birth control pills might play in breast cancer risk. Studies have found that women now using birth control pills have a slightly greater risk of breast cancer than women who have never used them. Women who stopped using the pill more than 10 years ago do not seem to have any increased risk. It's a good idea to discuss the risks and benefits of birth control pills with your doctor.

Postmenopausal hormone therapy (PHT; also called hormone replacement therapy): It has become clear that long-term use (several years or more) of combined PHT (estrogens together with progesterone) after menopause increases the risk of breast cancer as well as the risk of heart disease, blood clots, and strokes. The breast cancers are also found at a more advanced stage, perhaps because PHT seems to reduce the effectiveness of mammograms. Five years after stopping PHT, the breast cancer risk appears to drop back to normal. Estrogen alone (ERT) does not seem to increase the risk of breast cancer as much, if at all.

At this time, there appear to be few strong reasons to use PHT, other than for short-term relief of menopausal symptoms. Because there are other factors to think about, you should talk with your doctor about the pros and cons of using PHT.

Breast-feeding and pregnancy: Some studies have shown that breast-feeding slightly lowers breast cancer risk, especially if the breast-feeding lasts 1 to 2 years. This could be because breast-feeding lowers a woman's total number of menstrual periods, as does pregnancy. One study found that having more children and breast-feeding longer could reduce the risk of breast cancer by half.

Alcohol: Use of alcohol is clearly linked to a slightly increased risk of getting breast cancer. Women who have 1 drink a day have a very small increased risk. Those who have 2 to 5 drinks daily have about 1 times the risk of women who drink no alcohol. The American Cancer Society suggests limiting the amount you drink.

Obesity and high-fat diets: Being overweight is linked to a higher risk of breast cancer, especially for women after change of life and if the weight gain took place during adulthood. Also, the risk seems to be higher if the extra fat is in the waist area. But the link between weight and breast cancer risk is complex, and studies of fat in the diet as it relates to breast cancer risk have often given conflicting results.

Since diet and weight have been shown to affect the risk of getting several other types of cancer as well as heart disease, the American Cancer Society says it's best to stay at a healthy weight and limit your use of red meats, especially those high in fat or processed.

Exercise: Studies show that exercise reduces breast cancer risk. The only question is how much exercise is needed. One study found that as little as 1 hour and 15 minutes to 2 and a half hours per week of brisk walking reduced the risk by 18%. Walking 10 hours a week reduced the risk a little more. The American Cancer Society suggests that you exercise for 45 to 60 minutes 5 or more days a week.

Uncertain Risk Factors

A lot of research is being done to learn how the environment might affect breast cancer risk. At this time, research does not show a clear link between breast cancer risk and environmental pollutants, such as pesticides and PCBs.

Most studies have found no link between active cigarette smoking and breast cancer. Though both active smoking and secondhand smoke have been suggested to increase the risk of breast cancer in some studies, the issue remains controversial. The US Surgeon General is currently reviewing the evidence on this link, and a report is expected in late 2006. Regardless of the possible link between tobacco and breast cancer, not smoking cigarettes and limiting exposure to secondhand smoke is beneficial for a number of health reasons, including a reduced risk of other cancers and heart disease.

While a direct link between smoking and breast cancer has not been found, some studies suggest it might increase breast cancer risk, particularly for women who start smoking as teens. Smoking affects your overall health and increases the risk for many other cancers, as well as heart disease. If you smoke, you should make every attempt to quit.

Internet e-mail rumors have suggested that underarm antiperspirants can cause breast cancer. There is very little evidence to support this idea. Also, there is no evidence to support the idea that underwire bras cause breast cancer.

Several studies show that induced abortions do not increase the risk of breast cancer. Also, there is no evidence to show a direct link between miscarriages and breast cancer.

Silicone breast implants can cause scar tissue to form in the breast. But several studies have found that this does not increase breast cancer risk. If you have breast implants, you might need special x-ray pictures during mammograms.

A few recent studies have suggested that women who work at night (nurses on the night shift, for example) have a higher risk of breast cancer. But this has not yet been proven.

How Is Breast Cancer Found?

Screening refers to tests and exams used to find a disease, such as cancer, in people who do not have any symptoms. The earlier breast cancer is found, the better the chances that treatment will work. The goal is to find cancers before they start to cause symptoms. The size of a breast cancer and how far it has spread are the most important factors in predicting the outlook for the patient. Most doctors feel that early detection tests for breast cancer save many thousands of lives each year. Following the guidelines given here improves the chances that breast cancer can be found at an early stage and treated successfully.

ACS Guidelines for Early Breast Cancer Detection

The ACS recommends the following guidelines for finding breast cancer early in women without symptoms:

Mammogram: Women age 40 and older should have a mammogram every year and should continue to do so for as long as they are in good health. While mammograms can miss some cancers, they are still a very good way to find breast cancer.

Clinical breast exam: Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a regular exam by a health expert, preferably every 3 years. After age 40, women should have a CBE by a health expert every year. It might be a good idea to have the CBE shortly before the mammogram. You can use the exam to learn what your own breasts feel like.

Breast awareness and breast self-exam (BSE): BSE is an option for women starting in their 20s. Women should be told about the benefits and limitations of BSE. Women should report any changes in how their breasts look or feel to their health professional right away.

If you decide to do BSE, you should have your doctor or nurse check your method to make sure you are doing it right. If you do BSE on a regular basis, you get to know how your breasts normally look and feel. Then you can more easily notice changes. But it's OK not to do BSE or not to do it on a fixed schedule.

The most important thing is to see your doctor right away if you notice any of these changes: a lump or swelling, skin irritation or dimpling, nipple pain or the nipple turning inward, redness or scaliness of the nipple or breast skin, or a discharge other than breast milk. But remember that most of the time these breast changes are not cancer.

Women at high risk: Women with a higher risk of breast cancer should talk with their doctor about the best approach for them. This might mean starting mammograms when they are younger, having extra tests, or having more frequent exams.

Mammograms

A mammogram is an x-ray of the breast. This test is used to look for breast disease in women who appear to have no breast problems. It can also be used when women have symptoms such as those listed below.

During a mammogram, the breast is pressed between 2 plates to flatten and spread the tissue. The pressure lasts only for a few seconds. Although this may cause some discomfort for a moment, it is needed to get a good picture. Very low levels of radiation are used. While many people are worried about exposure to x-rays, the low level of radiation used for mammograms does not significantly increase the risk of breast cancer. For example, one mammogram gives off roughly the same amount of radiation a person would get flying from New York to California on a jet plane.

For the mammogram, you undress above the waist. You will have a wrap to cover yourself. A technologist (most often a woman) will position your breast correctly for the test. The pressure lasts only a few seconds while the picture is taken. The whole procedure takes about 20 minutes.

You will get your results within 30 days. If there is a problem, you will hear within 5 working days.

About 1 in 10 women who get a mammogram will need more pictures taken, but most of these women do not have breast cancer, so don't be alarmed if this happens to you. Only 1 or 2 mammograms of every 1,000 leads to a diagnosis of cancer.

Women with a higher risk of breast cancer should talk with their doctor about the best approach for them. They may benefit from starting mammograms when they are younger, having them more often, or having other tests. If you are at higher risk, your doctor might recommend ultrasound or MRI (magnetic resonance imaging).

Medicare, Medicaid, and most private health plans cover all or part of the cost of this test. And breast cancer testing is now more available to women without health insurance for free or at very little cost through a special program called the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Your state's Department of Health will have information about the program. There is also a new program to help pay for breast cancer treatment for women in need.

Clinical Breast Exam

A clinical breast exam (CBE) is an exam of your breasts by a health expert such as a doctor, nurse practitioner, nurse, or physician assistant. For this exam, you undress from the waist up. The examiner will first look at your breasts for changes in size or shape. Then, using the pads of the fingers, she or he will gently feel your breasts for lumps. The area under both arms will also be examined. This is a good time to learn how to do breast self-exam if you don't already know how.

Breast Awareness and Breast Self-Exam

Women should be aware of how their breasts normally look and feel and report any changes to their doctor right away. Finding a change does not mean that you have cancer.

By being aware of how your own breasts look and feel, you are likely to notice any changes that take place. You can also choose to use a step-by-step approach to checking your breasts on a set schedule. The best time to do breast self-examination (BSE) is when your breasts are not tender or swollen. If you find any changes, see your doctor right away.

Women with breast implants can do BSE. It may help to have the surgeon help identify the edges of the implant so that you know what you are feeling. It may be that the implants push out the breast tissue and actually make it easier to examine.

It's OK for women not to do BSE or to do it once in a while. The ACS has detailed information on how to do BSE for women who want to do it.

Symptoms of Breast Cancer

While the widespread use of screening mammograms has increased the number of breast cancers found before they cause any symptoms, some are still missed.

The most common sign of breast cancer is a new lump or mass. A lump that is painless, hard, and has uneven edges is more likely to be cancer. But some cancers are tender, soft, and rounded. So it's important to have anything unusual checked by your doctor.

Other signs of breast cancer include the following:

• a swelling of part of the breast
• skin irritation or dimpling
• nipple pain or the nipple turning inward
• redness or scaliness of the nipple or breast skin
• a nipple discharge other than breast milk
• a lump in the underarm area
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How Is Breast Cancer Treated?

This information represents the views of the doctors and nurses serving on the American Cancer Society's Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.

The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.

Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don't hesitate to ask him or her questions about your treatment options.

Local vs. Systemic Treatment

The purpose of local treatment is to treat a tumor without affecting the rest of the body. Surgery and radiation are examples of local treatment.

Systemic treatment is given into the bloodstream or by mouth to reach cancer cells that may have spread beyond the breast. Chemotherapy, hormone therapy, and immunotherapy are systemic treatments.

When people who seem to have no cancer left after surgery are given more treatment it is referred to as adjuvant therapy. Doctors now think that cancer cells can break away from the main tumor and begin to spread through the bloodstream in the early stages of the disease. It's very hard to tell if this has happened. But if it has, the cancer cells can start new tumors in other organs or the bones. The goal of adjuvant therapy is to kill these hidden cells, but not all patients need adjuvant therapy.

Some people are given systemic treatment (most likely chemotherapy) before surgery to shrink a tumor. This is called neoadjuvant therapy.

Types of Surgery for Breast Cancer

Most women with breast cancer will have some type of surgery to treat the main breast tumor. The purpose of surgery is to remove as much of the cancer as possible. Surgery can also be done to find out whether the cancer has spread to the lymph nodes under the arm (axillary dissection), to restore the breast's appearance (reconstructive surgery), or to relieve symptoms of advanced cancer. Here is a summary of some of the most common types of breast cancer surgery:

Lumpectomy (lump-ek-tuh-me): Also called breast conservation therapy, lumpectomy involves removing only the breast lump and some normal tissue around it. Radiation treatment is often given for about 6 weeks after this type of surgery. If chemotherapy is going to be used too, the radiation may be held until the chemo is finished.

Partial (segmental) mastectomy (mas-tek-tuh-me): This surgery involves removing more of the breast tissue than in a lumpectomy. It is usually followed by radiation therapy.

Simple or total mastectomy: In this surgery the entire breast is removed but not the lymph nodes under the arm or muscle tissue from beneath the breast. Sometimes both breasts are removed, especially if the woman is at very high risk for breast cancer. This surgery usually isn't much harder to recover from than having one breast removed. Either a single or double simple mastectomy has few side effects. Most women, if they are hospitalized, can go home the next day.

Modified radical mastectomy: This operation involves removing the entire breast and some of the lymph nodes under the arm.

Radical mastectomy: This is extensive removal of entire breast, lymph nodes, and the chest wall muscles under the breast. This surgery is rarely done now because modified radical mastectomy has proven to be just as effective with less disfigurement and fewer side effects.

Choosing Between Lumpectomy and Mastectomy

One advantage of lumpectomy is that it saves the way the breast looks. A downside is the need for several weeks of radiation after surgery. But some women who have a mastectomy will still need radiation. For most women with stage I or II breast cancer, lumpectomy or partial mastectomy (along with radiation) is as good as mastectomy. There is no difference in the survival rates of women treated with these 2 methods. Other factors, though, can affect which type of surgery is best for you. And lumpectomy is not an option for all women with breast cancer. Your doctor can tell you if there are reasons why a lumpectomy is not right for you.

Possible side effects of mastectomy and lumpectomy include infection and blood or fluid collecting at the place where the incision is made. If lymph nodes are removed, there could be other side effects as well such as swelling of the arm (lymphedema).

Other Breast Cancer Surgeries

Axillary dissection: This operation is done to find out if the breast cancer has spread to lymph nodes under the arm. Some nodes are removed and looked at under a microscope. Whether or not cancer cells are present in the lymph nodes under the arm is an important factor in choosing adjuvant therapy. It was once believed that removing as many lymph nodes as possible would reduce the risk of spread to other parts of the body and improve the chance of curing the cancer. It is now known that breast cancer cells that have spread beyond the breast and axillary lymph nodes are best treated by systemic therapy. Axillary dissection is used as a test to help guide other breast cancer treatment decisions.

A possible side effect of removing these lymph nodes is swelling of the arm, called lymphedema. It happens to between 1 and 3 out of 10 women who have had these nodes removed. Women who have swelling, tightness, or pain in the arm after lymph node surgery should be sure to tell their doctor right away. Often there are measures to prevent or reduce the effects of the swelling. The American Cancer Society has more information about lymphedema you can get by calling 1-800-ACS-2345 or on our Web site.

Sentinel lymph node biopsy: This is a way to look at the lymph nodes without having to remove all of them first. For this test, a radioactive substance and/or a dye are injected near the tumor. They are carried by the lymph system to the first (sentinel) node to receive lymph from the tumor. This lymph node is the one most likely to contain cancer cells if the cancer has spread. Once this node is found, it is removed and examined. If the sentinel node contains cancer, more lymph nodes are removed. If it is free of cancer, further lymph node surgery might not be needed. This type of biopsy is complex, so it is best to have it done by someone with a lot of experience in doing it.

Reconstructive or breast implant surgery: These operations are not meant to treat the cancer but are done to restore the way the breast looks after mastectomy. If you are having a mastectomy and are thinking about having breast reconstruction, you should talk to a plastic surgeon before your operation. There are several choices about when the surgery can be done and exactly what type it will be.

If you would like to talk to another woman who has had breast cancer, we encourage you connect with a volunteer in our Reach to Recovery program. A specially trained volunteer can provide information, comfort, and support. To learn more about Reach to Recovery or to request a visit, please call us at 1-800-ACS-2345.

What to Expect with Surgery

For many women, the thought of surgery can be frightening. But a better understanding of what to expect before, during, and after the operation may help ease your fears.

A few days after your biopsy you will know whether or not you have cancer, but the extent of the disease will not be known until after surgery. You will most likely meet with your surgeon a few days before the operation to talk about what will happen. You will be asked to sign a consent form giving the doctor permission to do the surgery. This is a good time to ask any questions you might have.

You may be asked to donate blood ahead of time in case you need it during the surgery. Your doctor will also ask you about medicines, vitamins, or supplements you are taking. You might need to stop taking some of them a week or two before surgery.

The type of anesthesia you will have depends largely on the kind of surgery being done and your own situation. How long the surgery will take and how long you will be in the hospital also depends on the type of surgery you are having.

As a rule, women having a mastectomy stay in the hospital for 1 or 2 nights and then go home. Lumpectomy and sentinel lymph node biopsy are usually done on an outpatient basis and do not require an overnight stay in the hospital.

The length of the operation also depends on the type of surgery you're having. For example, a mastectomy with lymph node removal will take from 2 to 3 hours.

After surgery you will have a bandage over the surgery site that may wrap snugly around your chest. You may have one or more tubes (drains) from the breast or underarm area to remove fluid that collects during the healing process. Most drains stay in place for a week or two. Once the flow has gone down to about one ounce a day, the drain will be removed.

Most doctors will want you to start moving the arm soon after surgery so that it won't get stiff. Women who have a lumpectomy or mastectomy are usually surprised by how little pain they have in the breast area. But they are less happy with the strange feelings (numbness, pinching/pulling) in the underarm area.

Talk with your doctor about what you should do after the surgery to care for yourself. You'll probably get written instructions that will tell you about the following:

• how to take care of the wound and dressing
• how to take care of the drains
• how to know if you have an infection
• when to call the doctor or nurse
• when to begin using the arm and how to do arm exercises to prevent stiffness
• when to start wearing a bra again
• when and how to wear a breast form
• what to eat and what not to eat
• what medicines to take (including pain medicines and maybe antibiotics)
• what activities you should or should not do
• what feelings you might have about how you look
• how to contact a Reach to Recovery volunteer -- these specially trained women can provide information, comfort, and support.

You will see your doctor a week or 2 after surgery. He or she should explain the results of your pathology report and talk to you about whether you will need further treatment.

Chemotherapy

Chemotherapy (commonly called just "chemo") is the use of cancer-killing drugs injected into a vein or taken as a pill. These drugs enter the bloodstream and reach throughout the body, making the treatment useful for cancers that have spread to distant organs. While these drugs kill cancer cells, they also damage some normal cells, which can lead to side effects.

Even in the early stages of the disease, cancer cells can break away from the first breast tumor and spread through the bloodstream. These cells don't cause symptoms, they don't show up on an x-ray, and they can't be felt during a physical exam. But if they are allowed to grow, they can form new tumors in other places in the body. Chemo can be given to find and kill these cells. Used in this way, it is called adjuvant therapy.

If chemo is given after surgery it can reduce the chance of breast cancer coming back. Chemo can also be used as the main treatment for a woman whose cancer has already spread outside the breast and underarm area or that spreads widely after the first treatment.

Chemo may be given before surgery, often to shrink the tumor in order to make it easier to remove. This approach also allows the doctors to watch how the tumor responds to the drugs. If the tumor does not shrink, different drugs can be used.

Chemo is given in cycles, with each period of treatment followed by a break. The total course of treatment usually lasts for 3 to 6 months. Often several drugs are used together rather than a single drug alone.

The side effects of chemo depend on the type of drugs used, the amount given, and the length of treatment. You could experience some of these temporary side effects:

• being very tired (called fatigue, often caused by a shortage of red blood cells)
• nausea and vomiting
• loss of appetite
• hair loss
• mouth sores
• changes in menstrual cycle (this could be permanent)
• a higher risk of infection (from a shortage of white blood cells)
• bruising or bleeding after minor cuts (from a shortage of blood platelets)

Most of these side effects go away when treatment is over. For example, your hair will grow back. If you have any problems with side effects, be sure to tell your doctor or nurse because there are often ways to help.

Permanent side effects can include early change of life (menopause) and not being able to become pregnant. But being on chemo does not always prevent pregnancy and getting pregnant while on chemo can lead to birth defects. If you are having sex, you should discuss birth control with your cancer doctor. Heart damage can occur if the drug Adriamycin is used for a long time or in high doses, but doctors are careful to control the dose of this drug and to watch for signs of problems.

Also, many women who have had chemo notice a slight decrease in concentration and memory ("chemo brain"). This may last a long time. Research has not confirmed these findings. Still, whether or not "chemo brain" is a real issue, women can and do function well after chemo. In studies that have found 'chemo brain' to be a side effect of treatment, the symptoms usually disappeared after 1 to 2 years.

Very rarely, years after treatment for breast cancer, certain chemo drugs may cause another cancer called acute myeloid leukemia. But the benefit of treating the breast cancer far outweighs the risk of this rare event.

Fatigue can be another long-lasting problem for women who have received chemotherapy. This may last up to several years, but it can be helped. Talk to your doctor if fatigue is a problem for you.

Radiation Therapy

Radiation therapy is treatment with high-energy rays (such as x-rays) to kill or shrink cancer cells. The radiation may come from outside the body (external radiation) or from radioactive materials placed directly in the tumor (brachytherapy).

Most often, external radiation is used for treating breast cancer. It is much like getting a regular x-ray but for a longer period of time. Radiation therapy may be used to destroy cancer cells remaining in the breast, chest wall, or underarm area after surgery or, less often, to reduce the size of a tumor before surgery.

Treatment is usually given 5 days a week in an outpatient center over a period of about 6 or 7 weeks, beginning about a month after surgery. Each treatment lasts a few minutes. The treatment itself is painless. If it is used along with chemotherapy, radiation is usually given after chemotherapy is finished.

The main side effects of radiation therapy are swelling and heaviness in the breast, sunburn-like changes in the treated area, and fatigue. These changes to the breast tissue and skin usually go away in 6 to 12 months. In some women, the breast becomes smaller and firmer after radiation therapy. Radiation therapy is not given during pregnancy because it can harm the fetus.

Another way to give radiation is to place radioactive seeds (pellets) into the breast tissue next to the cancer. It may be given to add an extra 'boost' of radiation to the tumor. It is also being studied as the only source of radiation. So far the results have been good, but more study is needed with this method before it can be used as standard treatment.

Another method being used is called 'Mammosite'. It consists of a balloon attached to a thin tube. The balloon is placed into the lumpectomy space and filled with salt water. Radioactivity is added through the tube. The radioactive material is added and removed twice a day for 5 days. Then the balloon is removed.

Hormone Therapy

The female hormone estrogen promotes the growth of breast cancer cells in some women. For these women, several methods to block the effect of estrogen or to lower its levels are used to treat breast cancer.

A drug such as tamoxifen, which blocks the effects of estrogen, can be given to counter the effects of estrogen. Tamoxifen is taken in pill form, usually daily for 5 years after surgery, to reduce the risk the cancer will come back. Recent studies have clearly shown that this drug helps women of all ages with early breast cancer if their cancer has estrogen receptors. It is also used to reduce the risk of getting breast cancer in women who are at high risk.

Some studies have shown an increase of early stage cancer of the lining of the uterus among women taking tamoxifen. But this cancer is usually found at a very early stage and is almost always cured by surgery. Tell your doctor right away if you have any unusual vaginal bleeding. Blood clots are another possible side effect of tamoxifen. Others can include hot flashes and mood swings. Still, for most women with breast cancer, the benefits of tamoxifen far outweigh the risks.

Aromatase inhibitors are a type of drug that stops the body from making estrogen. They only work for women who are past menopause and whose cancers are hormone positive. These drugs may be used after, or even instead of, tamoxifen to reduce the risk of the breast cancer coming back. They don't cause uterine cancer and very rarely cause blood clots. They can, however, cause bone thinning and fractures because they remove estrogens from the body.

There are several other treatments and drugs that affect female hormones which are being used for breast cancer. Your doctor can give you more details about any recommended treatments.

Targeted Therapy

As we have learned more about the gene changes that cause cancer, researchers have been able develop newer drugs that are aimed directly at these changes. These targeted drugs work differently than standard chemo drugs. They often have different (and less severe) side effects. At this time, they are most often used along with chemo.

Trastuzumab (Herceptin) is a monoclonal antibody that attaches to a growth-promoting protein (HER2/neu) that is found in small amounts on the surface of normal breast cells and most breast cancers. Some breast cancers have too much of this protein, which can cause the cancer to grow and spread faster. Herceptin can stop this protein from causing breast cancer cell growth. It may also help the immune system to better attack the cancer. (Monoclonal antibodies are man-made versions of the immune system proteins that the body makes to fight diseases.)

Recent studies have shown that adding 1 year of Herceptin treatment to chemo lowers the rate of cancer coming back and the death rate over chemo alone after surgery for certain women. This approach has become standard adjuvant treatment in these cases.

The side effects of this drug are fairly mild. They may include fever and chills, weakness, nausea, vomiting, cough, diarrhea, and headache. But some women may have heart damage during treatment. This damage can improve if the drug is stopped. If you are having this treatment, you should tell your doctor right away if you have any shortness of breath, swelling, or trouble with physical activities.

Lapatinib (Tykerb) is another drug that targets the HER2/neu protein. This drug is given as a pill, most often along with chemo. It is used for some women with cancer that is no longer helped by chemo and Herceptin. This drug can cause side effects, but does cause the heart problems that Herceptin may cause in some women.

Drugs That Target Tumor Blood Vessels

Bevacizumab (Avastin) is another monoclonal antibody that may be used in patients with breast cancer that has spread. It is also used along with other chemo drugs. This antibody helps to prevent tumors from forming new blood vessels to feed the tumor. Avastin is given by intravenous infusion. There can be some rare, though serious, side effects.

Bisphosophonates

Two drugs (bisphosphonates) that help strengthen bones are used in breast cancer treatment. They can strengthen bones that have been weakened by invading breast cancer cells. The drugs are given into a vein to help prevent bone damage if the cancer has spread to the bone. There have been reports of a serious side effect from bisphosphonates. The jaw bone can deteriorate and become painful. Doctors don't know why this happens. It seems to occur in patients who have had dental work done while on the drugs. Therefore, dental work should be done before starting these drugs.

In the past, it was thought that very high doses of chemotherapy followed by a method called stem cell transplant might offer some women with a high risk of the cancer coming back or with advanced cancer the best chance for a cure. But doctors have found that the women who received high dose therapy did not live any longer than women who had standard dose chemotherapy. And high dose chemotherapy with stem cell support can cause serious side effects. Research in this area is still going on. For now, experts in the field suggest that women receive this treatment only as part of a clinical trial.