Treatment usually begins within a few weeks after diagnosis. Unless the cancer is detected at an extremely advanced stage and your life is in immediate jeopardy, you generally have time to get a second opinion and discuss the various treatment options available, which may include a combination of such things as chemotherapy, radiation and surgery.
Your health care team may include surgeons, oncologists, plastic surgeons, radiation oncologists, as well as your own physician. Breast cancer is a serious disease that often requires the attention of numerous medical specialists. Coordinating all of the information from each of these doctors can become overwhelming. That is why it is generally a good idea to have someone accompany you to the doctor when discussing your treatment options.
Treatment for breast cancer is often complex and depends on a variety of factors. Treatment for breast cancer can involve surgery, chemotherapy, radiation therapy, and hormone-blocking medications. There is no one standard treatment plan. You and your doctor together will need to discuss the best course. Treatment will depend on size, type and location of the tumor, stage of the disease, your age, menopausal status, general health, and the size of your breasts. Women with small breasts are usually not good candidates for breast-preserving surgery. Different types of tumors respond to different types of medication.
Your doctor is the best source of information on the drug treatment choices available to you.
Radiation therapy, which uses high-energy rays, is often used with surgery to kill any remaining cancerous cells. Radiation may be used before surgery to help shrink tumors, after lumpectomy, and after mastectomy if the tumor was large or if many lymph nodes were involved. There are two types of radiation treatments: external and internal.
In external radiation, the rays come from a machine positioned outside of the body. Patients generally have to go to the hospital every day for approximately 6 weeks in order to receive treatments. In internal radiation, the radiation comes from an implant—radioactive material is placed directly into the breast by way of thin plastic tubes. This latter form is much less common.
Radiation, like chemotherapy, is associated with certain side effects, although they are less severe. Side effects of radiation therapy may include: fatigue, reddening or blistering of the skin, and changes in the color of the skin. Rare side effects may include rib fractures, lung inflammation, cough, and shortness of breath.
Newer therapies are constantly being developed and tested. Ask your doctor about becoming involved with a clinical trial to test experimental drugs or treatments for breast cancer. The Physician Data Query system (http://www.cancernet.nci.nih.gov/pdqfull.html), which is produced by the National Cancer Institute, has been established to give both patients and physicians information on clinical trials.
Some treatments being used experimentally involve trying to change the body’s immune system so that it fights cancer cells. Bone marrow transplant is also an experimental approach to treating breast cancer that is currently being studied.
Removal of the tumor and some normal tissue gives the best chance of preventing cancer from recurring within the breast. There are several surgical treatment options available to women who have been diagnosed with breast cancer. Which option is chosen will in part depend on the size and location of the tumor, the stage of the tumor, the size of the breast, and your personal desires. The types of surgical interventions include:
- Lumpectomy: For small tumors, this procedure removes the lump and surrounding breast tissue. Radiation to the breast is recommended after lumpectomy.
- Quadrantectomy: Removes one-fourth of the breast tissue
- Mastectomy: Complete removal of the breast. This is generally recommended for larger tumors, or for women with small breasts
- Simple mastectomy: All breast tissue is removed, but the underlying muscles are left intact and enough underlying skin is left to cover the wound
- Modified radical mastectomy: Removes all breast tissue and lymph nodes under the arm and often the lining over the chest muscle.
- Radical mastectomy: Removes all of the breast tissue, chest muscles, all of the lymph nodes under the arm and some additional fat and skin. Today, this is only used for advanced cases where the cancer has spread to the chest muscles.
After a mastectomy, many women chose to have breast reconstruction surgery. The breast is rebuilt using implants or tissue removed from other parts of the body. You can have this procedure done immediately following a mastectomy, or you can wait until after any additional treatment such as radiation and chemotherapy is finished.
Depending on the situation, one to several lymph nodes under the arm may be removed during surgery to determine whether the cancer has spread from beyond the original lump. This is done because the lymph system acts as a collection point for waste products from cells. If cancer cells have broken away from the tumor, they will most likely travel to the nearest lymph node. If the node does not hold cancerous cells, then the tumor may not have spread. However, removing the lymph nodes can result in swelling of the arm, a complication called lymphedema.
A new procedure called “sentinel” lymph node biopsy can now determine which specific lymph node needs to be removed. A tracer dye and/or radioactive compound is injected into the patient at the site of the tumor. By following the path of the dye (which is either colored blue or slightly radioactive), surgeons can determine which node the cancer would first spread to. The optimal use of sentinel lymph node biopsy is still being studied.
Even though the breast is not removed during a conserving surgery such as lumpectomy, the treated breast can change in appearance. It can become smaller, or the contour can change. Breast-conserving surgery is not recommended for everyone. People who should not have this type of surgery include:
- Women with tumors larger than 5 cm
- Women with smaller tumors but who have small breasts
- Tumors involving the nipple area
- Tumors that involve many parts of the breast
- Women unable to take radiation therapy after lumpectomy, including pregnant women and those with a serious collagen vascular disease, such as lupus.
As with all surgeries, there are side effects of breast surgery to be aware of. These include: pain, risk of infections, poor wound healing, bleeding, reduced strength, and numbness and tingling in the chest, underarm, and shoulder.
You hand and arm may swell as a result of the removal of the lymph nodes. You may also experience back and neck pain because removing the breast may cause your weight to shift and become distributed differently.
More than 1,000 men in the U.S. get breast cancer every year. While men are 150 times less likely to develop breast cancer than women, male breast cancer should not be ignored. Usually, the first sign is a lump in the breast, which tends to be misdiagnosed. In general, men are diagnosed at a later stage of the disease. However, when matched against women with the same stage and age, the prognosis for men is the same.
Any mass in the breast of a man should be thoroughly examined. The risk for developing breast cancer is higher for men with enlargement of the breast tissue (gynecomastia). A modified radical mastectomy is the usual course of treatment for men. Radiation may also be given. Almost 90% of men with breast cancer have the type of tumors that respond to hormone therapy.
Male breast cancer is similar to female breast cancer in that the information on symptoms, diagnosis, treatment, and living with the disease is the same. Men, however, do not need routine screening. Support and counseling may be beneficial to men with breast cancer, since it is so rare.
There are factors that can help determine the prognosis of the patient with early breast cancer. However, it is almost impossible to predict an outcome in each case. The number of lymph nodes involved, the size of the tumor, the grade (or aggressiveness) of the tumor, and whether the tumor has hormone receptors are the major factors that doctors rely on to make a prognosis. In general, the following often account for a poor prognosis in early breast cancer:
- Patients with many lymph nodes that are positive for cancer
- Inflammatory breast cancer
- Patients with large tumors
- Patients whose tumors are the type that will not respond to hormone treatment
- Patients with tumors whose tissue is very different from normal breast tissue. Some tumors have cells that are still closely related to normal breast cells, and some tumors have cells that barely resemble breast cells. Tumors that are very different from normal tissue are often stronger and more aggressive (referred to as high grade).
Thirty percent of patients without node involvement and 75% of patients with node involvement at diagnosis will develop metastatic disease (cancer that has spread to other tissues). Metastatic disease generally develops within five years after the initial diagnosis, although it can occur as many as 10 or more years later. Metastatic disease (Stage IV) is incurable. The five-year survival rate is about 5 to 10%.
Follow-up will require frequent doctor visits, often every three to four months for the first five years after the initial diagnosis. Follow-up visits should focus on determining whether cancer has appeared in the opposite breast, in the same breast, or in areas other than the breasts. In general, signs and symptoms often lead to the diagnosis of a recurrence. That is why it is important to inform your physician about any changes in your health such as coughing, dizziness, headaches, or pain, no matter how minor they seem. While these symptoms may be due to common problems, such as a cold, recurrence needs to be considered a possibility. The use of routine x-rays and blood tests is not recommended, as these tests have not been found to find disease earlier or to improve survival.
You may find that you need a great deal of emotional support after diagnosis and throughout treatment. There are many survival groups that can help you and your family cope with the feelings of depression, fear, anger, and pain that you may experience. You may find yourself overwhelmed with thoughts of the future. You may wonder why cancer had to happen to you, or what made you deserve the diagnosis. You will need to be very resilient, both physically and emotionally, to withstand diagnosis and treatment. It is important that you and your loved ones understand the issues of cancer so that the depression and fear can turn into acceptance and courage. Talk to your doctor about your feelings and ask for assistance in finding support groups. Communicating with other survivors can be extremely comforting.
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