BREAST CANCER

Treatment

A diagnosis of breast cancer is one of the most difficult experiences you can face. In addition to coping with a life-threatening illness, you must make complex decisions about treatment. Remember, in most cases no one right treatment exists for breast cancer. Instead, you'll want to find the approach that's best for you.

To do that, you'll need to consider many different factors, including the type and stage of your cancer, your age, risk factors, where you are in your life, the size and shape of your breasts, and your feelings about your body.

Before making any decisions, learn as much as you can about the many treatment options that exist. Talk extensively with your health care team. Consider a second opinion from a breast specialist in a breast center or clinic. Don't be afraid to ask questions. In addition, look for breast cancer books, Web sites and information available from organizations such as the American Cancer Society and the Susan G. Komen Foundation. Talking to other women who have faced the same decision also may help. This may be the most important decision you ever make.

Treatments exist for every type and stage of breast cancer. Most women will have surgery and an additional (adjuvant) therapy such as radiation, chemotherapy or hormone therapy. Biological therapy, which uses your body's own immune system to fight cancer, is currently being tested in clinical trials.

Surgery

At one time, the only type of breast cancer surgery was radical mastectomy, which removed the entire breast, along with chest muscles beneath the breast and all the lymph nodes under the arm. Today, this operation is rarely performed. Instead, the majority of women are candidates for breast-saving operations, such as lumpectomy. Less radical mastectomies and mastectomy with reconstruction are also options.

Breast cancer operations include the following:

• Lumpectomy. This operation saves as much of your breast as possible by removing only the lump plus a surrounding area of normal tissue. Your surgeon will likely also remove some lymph nodes to check for possible spread of cancer. In most cases, your operation will be followed by radiation therapy to kill any remaining cancer cells. You usually have radiation therapy every weekday for 6 to 7 weeks. Many women can have lumpectomy plus radiation instead of mastectomy, and in most cases survival rates for both operations are the same. In addition, many more women are satisfied with their appearance after lumpectomy. But lumpectomy may not be an option if a tumor is deep within your breast, or if you've already had radiation therapy, have two or more areas of cancer in the same breast that are far apart, have a connective tissue disease that makes you sensitive to radiation or are pregnant. It's important to keep in mind that if you choose lumpectomy, you'll often also need radiation.

• Partial or segmental mastectomy. Also considered a breast-sparing operation, partial mastectomy involves removing the tumor as well as some of the breast tissue around the tumor and the lining of the chest muscles that lie beneath it. Some lymph nodes under your arm also may be removed. In almost all cases, you'll have a course of radiation therapy following your operation.

• Simple mastectomy. During a simple mastectomy, your surgeon removes all your breast tissue — the lobules, ducts, fatty tissue and a strip of skin with the nipple. Depending on the results of the operation and follow-up tests, you may also need further treatment with radiation, chemotherapy or hormone therapy.

• Modified radical mastectomy. In this procedure, a surgeon removes your entire breast and some underarm (axillary) lymph nodes, but leaves your chest muscles intact. This makes breast reconstruction less complicated. Arm swelling (lymphedema) — a common complication of mastectomy — is also less likely to occur. Your lymph nodes will be tested to see if the cancer has spread. Depending on those results, you may need further treatment.

• Sentinel lymph node biopsy. Breast cancer first spreads to the lymph nodes under the arm. That's why all women with invasive cancer need to have these nodes examined. If your surgeon doesn't plan to do this, be sure you understand the reason why. Until recently, surgeons would remove as many lymph nodes as possible. But this greatly increased the risk of lymphedema — a serious swelling of the arm. That's why a new procedure has been developed that focuses on finding the sentinel nodes — the first nodes to receive the drainage from breast tumors and therefore the first to develop cancer. If a sentinel node is removed, examined and found to be healthy, the chance of finding cancer in any of the remaining nodes is very small and no other nodes need to be removed. This spares many women the need for a more extensive operation and greatly decreases the risk of complications.

Reconstructive surgery

Most women who undergo mastectomy are able to choose whether or not to have breast reconstruction. This is a very personal decision, and there is no right or wrong choice. You may find, however, that you have feelings about your breasts you didn't expect. It's important to understand these feelings before making any decision.

If you would like reconstruction, but aren't a candidate for the procedure, you'll need to find a way to come to terms with your disappointment. It may be extremely helpful to talk to other women who have experienced the same situation.

If reconstruction is an option, your surgeon will refer you to a plastic surgeon. He or she can describe the procedures to you and show you photos of women who have had different types of reconstruction. Your options include reconstruction with a synthetic breast implant or reconstruction using your own tissue to rebuild your breast. These operations can be performed at the time of your mastectomy or at a later date.

• Reconstruction with implants. Using artificial materials to reconstruct your breast involves implanting a silicone shell filled either with silicone gel or salt water (saline). If you don't have enough muscle and skin to cover an implant, you doctor may use a tissue expander. This is an empty implant shell that inflates as fluid is injected. It's placed under your skin and muscle, and your doctor gradually fills it with fluid — usually over a period of several months. When your muscle and skin have stretched enough, the expander is removed and replaced with a permanent implant. Recovery may take several weeks. In general, an implant makes your breast firmer than a normal breast. It's also important to know that implants are the subject of increasing controversy. The Food and Drug Administration warns that breast implants can make it harder to detect lumps during breast exams and on mammograms. Breast implants also have a high failure rate, often subjecting women to repeat operations. One study showed that 40 percent of women had to have implants replaced in the first 3 years after mastectomy. Replacement surgery is costly and exposes you to unnecessary risks. It also can be difficult emotionally.

• Reconstruction with your own tissue. Known as a transverse rectus abdominis myocutaneous (TRAM) flap, this surgery reconstructs your breast using tissue from your abdomen. Sometimes your surgeon may also use tissue from your back or buttocks. Because the procedure is fairly complicated, recovery may take 6 to 8 weeks. You also may need future adjustments to the breast. Complications include the risk of infection and tissue death. If you have little body fat, this type of reconstruction may not be an option for you. On the other hand, a breast reconstructed from your own tissue doesn't seem to interfere with the detection of tumors. It's also permanent, and has the look and feel of a normal breast.

• Reconstruction of your nipple and areola. After initial surgery with either tissue transfer or an implant, you may also have reconstruction of your nipple and areola. Using tissue from elsewhere in your body, your surgeon first creates a small mound to resemble a nipple. He or she may then tattoo the skin around the nipple to create an areola. Your surgeon may also take a skin graft from elsewhere on your body, place it around the reconstructed nipple to slightly raise the skin and then tattoo the skin graft.

Radiation therapy

Radiation therapy uses high energy X-rays to kill cancer cells and shrink tumors. If you choose lumpectomy, or if a biopsy has confirmed that there are cancer cells in more than four lymph nodes in your armpit, your oncologist will likely recommend radiation. Although the thought of radiation can be disturbing, it may help to know that it's a more accurate and less aggressive treatment than it once was.

Radiation is usually started 3 to 4 weeks after surgery. You'll typically receive treatment 5 days a week for 6 to 7 weeks. The treatments are painless and are similar to getting an X-ray. Each takes about 30 minutes. The effects are cumulative, however, and you may become tired toward the end of the series. Your breast may be pink, puffy and somewhat tender, as if it had been sunburned.

There is also a chance that young women who choose lumpectomy and radiation may have long-term complications from radiation exposure. These include changes in the appearance and consistency of breast tissue. In extremely rare cases, a new tumor may result from radiation.

Chemotherapy

Chemotherapy uses drugs to destroy cancer cells. Your doctor may recommend chemotherapy following surgery to kill any cancer cells that may have spread outside your breast. Treatment often involves receiving two or more drugs in different combinations. These may be administered intravenously, in pill form or both. You may have between 4 and 8 treatments spread over 3 to 6 months.

Sometimes chemotherapy can feel like another illness. The side effects may include hair loss, nausea, vomiting and fatigue. These occur because chemotherapy affects healthy cells — especially fast-growing cells in your digestive tract, hair and bone marrow — as well as cancerous ones. Not everyone has side effects, however, and there are now better ways to control them if you do.

Many new drugs can help prevent or greatly reduce nausea. Relaxation techniques, including guided imagery, meditation and deep breathing also may help. In addition, exercise has been shown to be effective in reducing fatigue caused by chemotherapy.

Hormone therapy

Hormone therapy may be an option for you if your hormone receptor test is positive. A positive test means estrogen or progesterone might encourage the growth of breast cancer cells in your body. Normally, estrogen and progesterone bind to sites on your breast cells. But during this treatment, a hormonal medication binds to these sites instead and prevents estrogen from reaching them. This reduces the chances that your cancer will recur.

The medication used most commonly is tamoxifen (Nolvadex). You take it daily, in pill form, for up to 5 years. It may reduce the risk of recurrence by about one-half and is less toxic than most anticancer drugs. But tamoxifen isn't trouble free. Women taking tamoxifen may experience menopausal symptoms such as night sweats, hot flashes, vaginal itch or discharge and diminished sexual interest. Other less common but potentially troubling side effects can also occur. These include the development of blood clots and the very rare development of endometrial cancer.

Biological therapy

Sometimes called biological response modifier or immunotherapy, this treatment tries to stimulate your body's immune system to fight cancer. Using substances produced by the body or similar substances made in a laboratory, biological therapy seeks to enhance your body's natural defenses against specific diseases. This therapy is experimental and only available in clinical trials. One medication known as trastuzumab (Herceptin) is available for treating certain advanced cases of breast cancer.

Clinical trials

A number of new approaches to treating cancer are being studied. The emphasis is on methods that can successfully treat women or extend their survival with minimal side effects. Among these are drugs that block the biochemical switches that cause normal cells to turn cancerous. In addition, a procedure known as anti-angiogenesis — which targets the blood vessels that supply nutrients to cancer cells — is also being studied. And gene therapy is an area of ongoing research.

Some of these new treatments are available through clinical trials — the standard way new therapies are tested in people.