Breast Cancer
Breast cancer is the second most common cancer among women after skin cancer and, of cancers, is the second most common cause of death among women after lung cancer. In 2001, breast cancer was diagnosed in about 200,000 women in the United States. About one fifth of them will die of it.
Many women fear breast cancer, because it is common. However, some of the fear about breast cancer is based on misunderstanding. For example, the statement, "One of every eight women will get breast cancer," is misleading. That figure is an estimate based on women from birth to age 95. It means that theoretically, one of eight women who live to age 95 or older will develop breast cancer. However, a 40-year-old woman has only a 1 in 1,200 chance of developing breast cancer during the next year and about a 1 in 120 chance of developing it during the next decade. But as she ages, her risk increases.
Other factors also affect the risk of developing breast cancer. Thus, for some women, the risk is much higher or lower than average. Most factors that increase risk, such as age, cannot be modified. However, regular exercise, particularly during adolescence and young adulthood, and possibly weight control may slightly reduce the risk of developing breast cancer. Regularly drinking alcoholic beverages may increase the risk.
Far more important than trying to modify risk factors is being vigilant about detecting breast cancer so that it can be diagnosed and treated early, when it is more likely to be cured. Early detection is more likely when women have mammograms and perform breast self-examinations regularly (see Section 22, Chapter 251 and Section 22, Chapter 251).
 See the table What Are the Risks of Developing or Dying of Breast Cancer?
 See the sidebar Risk Factors for Breast Cancer.
Staging
Staging involves assigning a stage to a cancer when it is diagnosed. The stage is based on how advanced the cancer is. The stage helps doctors determine the most appropriate treatment and the prognosis. Stages of breast cancer may be generally described as in situ (not invasive), localized invasive, regional invasive, or distant (metastatic) invasive. Or, stages may be described in detail and designated by a number (0 through IV).
Carcinoma in situ means cancer in place. It is the earliest stage of breast cancer. Carcinoma in situ may be large and may even affect a substantial area of the breast, but it has not invaded the surrounding tissues or spread to other parts of the body. More than 15% of all breast cancers diagnosed in the United States are carcinoma in situ. It is usually detected during mammography.
Localized invasive cancer has invaded surrounding tissues but is confined to the breast.
Regional invasive cancer has invaded tissues near the breasts, including the chest wall and lymph nodes.
Distant (metastatic) invasive cancer has spread from the breast to other parts of the body. Cancer tends to move into the lymphatic vessels in the breast. Most lymphatic vessels in the breast drain into lymph nodes in the armpit (axillary lymph nodes). One function of lymph nodes is to filter out and destroy abnormal or foreign cells, such as cancer cells. If cancer cells get past these lymph nodes, the cancer can spread anywhere in the body. Breast cancer can also spread through the bloodstream to other parts of the body. Breast cancer tends to spread to bones and the brain but can spread to any area, including the lungs, liver, and skin. Breast cancer can appear in these areas years or even decades after it is first diagnosed and treated. If the cancer has spread to one area, it probably has spread to other areas, even if it is not detected right away.
Types
Breast cancer is usually classified by the kind of tissue in which the cancer starts and by the extent of its spread. Breast cancer that starts in the milk ducts is called ductal carcinoma. About 90% of all breast cancers are this type. Breast cancer that starts in the milk-producing glands (lobules) is called lobular carcinoma. Breast cancer that starts in fatty or connective tissue, a rare type, is called sarcoma.
Ductal carcinoma in situ is confined to the milk ducts of the breast. It does not invade surrounding breast tissue, but it can spread along the ducts and gradually affect a substantial area of the breast. This type accounts for 20 to 30% of breast cancers.
Lobular carcinoma in situ grows within the milk-producing glands of the breast. It often occurs in several areas of both breasts. Women with lobular carcinoma in situ have a 30% chance of developing invasive breast cancer in the same or other breast during the next 24 years. This type accounts for 1 to 2% of breast cancers.
Invasive ductal carcinoma begins in the milk ducts but breaks through the wall of the ducts, invading the surrounding breast tissue. It can also spread to other parts of the body. It accounts for 65 to 80% of breast cancers.
Invasive lobular carcinoma begins in the milk-producing glands of the breast but invades surrounding breast tissue and spreads to other parts of the body. It is more likely than other types of breast cancer to occur in both breasts. It accounts for 10 to 15% of breast cancers.
Inflammatory breast cancer is fast growing and often fatal. Cancer cells block the lymphatic vessels in the skin of the breast, causing the breast to appear inflamed: swollen, red, and warm. Usually, inflammatory breast cancer spreads to the lymph nodes in the armpit. The lymph nodes can be felt as hard lumps. However, often no lump may be felt in the breast itself because this cancer is dispersed throughout the breast. Inflammatory breast cancer accounts for about 1% of breast cancers.
Paget's disease of the nipple is a type of ductal breast cancer. The first symptom is a crusty or scaly nipple sore or a discharge from the nipple. Slightly more than half of the women who have this cancer also have a lump in the breast that can be felt. Paget's disease may be in situ or invasive. Because this disease usually causes little discomfort, a woman may ignore it for a year or more before seeing a doctor. The prognosis depends on how invasive and how large the cancer is as well as whether it has spread to the lymph nodes.
Less common types of invasive ductal breast cancers include medullary carcinoma, tubular carcinoma, and mucinous (colloid) carcinoma. Mucinous carcinoma tends to develop in older women and to be slow growing. Women with these types of breast cancer have a much better prognosis than women with other types of invasive breast cancer.
Cystosarcoma phyllodes is a relatively rare type of breast cancer. It originates in breast tissue around milk ducts and milk-producing glands. It spreads to other parts of the body in fewer than 5% of women who have it.
See the table Stages of Breast Cancer.
Characteristics
All cells, including breast cancer cells, have molecules on their surfaces called receptors. A receptor has a specific structure that allows only particular substances to fit into it and thus affect the cell's activity. Whether breast cancer cells have certain receptors affects how quickly the cancer spreads and how it should be treated.
Some breast cancer cells have receptors for estrogen. The resulting cancer, described as estrogen receptor-positive, is stimulated by estrogen. This type of cancer is more common among postmenopausal women than among younger women. Some breast cancer cells have receptors for progesterone. The resulting cancer, described as progesterone receptor-positive, is stimulated by progesterone. Estrogen receptor-positive breast cancers grow more slowly than estrogen receptor-negative breast cancers, and the prognosis is better. The same is true for progesterone receptor-positive and progesterone receptor-negative breast cancers. The prognosis is better with cancer that is both estrogen and progesterone receptor-positive than with cancer that is one or the other.
Cells have receptors called HER-2/neu receptors that help them grow. Breast cancer cells with too many HER-2/neu receptors tend to be very fast growing. In about 20 to 30% of breast cancers, the cancer cells have too many HER-2/neu receptors.
Symptoms
At first, a woman who has breast cancer has no symptoms. Most commonly, the first symptom is a lump, which usually feels distinctly different from the surrounding breast tissue. In more than 80% of breast cancer cases, the woman discovers the lump herself. Usually, scattered lumpy changes in the breast, especially the upper outer region, are not cancerous and indicate fibrocystic breast disease. A firm, distinctive thickening that appears in one breast but not the other may indicate cancer.
In the early stages, the lump may move freely beneath the skin when it is pushed with the fingers. In more advanced stages, the lump usually adheres to the chest wall or the skin over it. In these cases, the lump cannot be moved at all or it cannot be moved separately from the skin over it. One way to detect even slight adherence of a cancer to the chest wall or skin is to lift the arms over the head while standing in front of a mirror. A breast containing cancer may show skin puckering or another shape abnormality compared with the other breast. In advanced cancer, swollen bumps or festering sores may develop on the skin. Sometimes the skin over the lump is dimpled and leathery and looks like the skin of an orange (peau d'orange) except in color.
The lump may be painful, but pain is an unreliable sign. Pain without a lump is rarely due to breast cancer.
Lymph nodes, particularly those in the armpit on the affected side, may feel like hard small lumps. The lymph nodes may be stuck together or adhere to the skin or chest wall. They are usually painless but may be slightly tender.
In inflammatory breast cancer, the breast is warm, red, and swollen, as if infected (but it is not). The skin of the breast may become dimpled and leathery, like the skin of an orange, or may have ridges. The nipple may turn inward (invert). A discharge from the nipple is common. Often, no lump can be felt in the breast.
Screening
Because breast cancer rarely produces symptoms in its early stages and because early treatment is more likely to be successful, screening is important. Screening is the hunt for a disorder before any symptoms occur.
 See the figure How to Perform a Breast Self-Examination.
Routine self-examination enables a woman to detect lumps at an early stage. Self-examination does not reduce the death rate from breast cancer or detect as many early cancers as routine screening with mammography. With tumors detected by self-examination, the prognosis is usually better, and breast-conserving surgery can usually be performed rather than mastectomy.
A breast examination is a routine part of a physical examination. A doctor inspects the breasts for irregularities, dimpling, tightened skin, lumps, and a discharge. The doctor feels (palpates) each breast with a flat hand and checks for enlarged lymph nodes in the armpit--the area most breast cancers invade first--and also above the collarbone. Normal lymph nodes cannot be felt through the skin, so those that can be felt are considered enlarged. However, noncancerous conditions can also cause lymph nodes to enlarge. Lymph nodes that can be felt are checked to see if they adhere to the skin or chest wall and if they are matted together.
Mammography uses low-level x-rays to detect abnormal areas in the breast. It is one of the best ways to detect breast cancer early (see Section 22, Chapter 242). Mammography is designed to be sensitive enough to detect the possibility of cancer at an early stage. For this reason, the procedure may indicate cancer when none is present--a false-positive result. Typically, when the result is positive, more specific follow-up procedures, usually a breast biopsy, are scheduled to confirm the result. Mammography may miss up to 15% of breast cancers.
Having a mammogram every 1 to 2 years can reduce the rate of death due to breast cancer by 25 to 35% among women aged 50 and older. As yet, no study has shown that having mammograms regularly can reduce the death rate among women younger than 50. However, evidence may be harder to obtain because breast cancer is not common among younger women. Many experts recommend that women aged 40 to 49 have mammograms every 1 to 2 years. All experts recommend yearly mammograms for women aged 50 and older.
Diagnosis
When a lump or another suspicious change is detected in the breast during a physical examination or by a screening procedure, other procedures are necessary. Mammography is performed first if it was not the way the abnormality was detected.
Ultrasonography is sometimes used to help distinguish between a fluid-filled sac (cyst) and a solid lump. This distinction is important because cysts are usually not cancerous. Cysts may be monitored (with no treatment) or drained with a small needle and syringe. Rarely, when cancer is suspected, cysts are removed. If the abnormality is a solid lump, which is more likely to be cancerous, a biopsy is performed. Often, an aspiration biopsy is performed: Some cells are removed from the lump through a needle attached to a syringe. If this procedure detects cancer, the diagnosis is confirmed. If no cancer is detected, removal of an additional piece of tissue (incisional biopsy) or of the entire lump (excisional biopsy) is necessary to be sure that the aspiration biopsy did not miss the cancer. Most women do not need to be hospitalized for these procedures. Usually, only a local anesthetic is needed.
If Paget's disease of the nipple is suspected, a biopsy of nipple tissue is performed. Sometimes this cancer can be diagnosed by examining a sample of the nipple discharge under a microscope.
A pathologist examines the biopsy samples under the microscope to determine whether cancer cells are present. Generally, a biopsy confirms cancer in one of four women in whom mammography detects an abnormality. If cancer cells are detected, the sample is analyzed to determine the characteristics of the cancer cells, such as whether the cancer cells have estrogen or progesterone receptors, how many HER-2/neu receptors are present, and how quickly the cancer cells are dividing. This information helps doctors estimate how rapidly the cancer may spread and which treatments are more likely to be effective.
A chest x-ray is taken and blood tests to evaluate liver function are performed to determine whether the cancer has spread. If the tumor is large or if the lymph nodes are enlarged, x-rays of bones throughout the body (a bone scan) may be taken.
Treatment
Usually, treatment begins after the woman's condition has been thoroughly evaluated, about a week or more after the biopsy. Treatment options depend on the stage and type of breast cancer. However, treatment is complex because the different types of breast cancer differ greatly in growth rate, tendency to spread (metastasize), and response to treatment. Also, much is still unknown about breast cancer. Consequently, doctors may have different opinions about the most appropriate treatment for a particular woman.
The preferences of a woman and her doctor affect treatment decisions. A woman with breast cancer should ask for a clear explanation of what is known about the cancer and what is still unknown, as well as a complete description of treatment options. Then, a woman can consider the advantages and disadvantages of the different treatments and accept or reject the options offered. Losing some or all of a breast can be emotionally traumatic. A woman must consider how she feels about this treatment, which can deeply affect her sense of wholeness and sexuality.
Doctors may ask a woman with breast cancer to participate in research studies investigating a new treatment, which may improve her chances of survival or her quality of life. All women who participate in a research study are treated, because a new treatment is compared with other effective treatments. A woman should ask her doctor to explain the risks and possible benefits of participation, so that she can make a well-informed decision.
Treatment usually involves surgery and may include radiation therapy, chemotherapy, or hormone-blocking drugs. Often, a combination of these treatments is used.
 See the figure Surgery for Breast Cancer.
Surgery: The cancerous tumor and varying amounts of the surrounding tissue are removed. There are two main options for removing the tumor: breast-conserving surgery and removal of the breast (mastectomy).
Breast-conserving surgery leaves as much of the breast intact as possible. There are several types:
- Lumpectomy is removal of the tumor with a small amount of surrounding normal tissue
- Wide excision or partial mastectomy is removal of the tumor and a somewhat larger amount of surrounding normal tissue
- Quadrantectomy is removal of one fourth of the breast
Removing the tumor with some normal tissue provides the best chance of preventing cancer from recurring within the breast. Breast-conserving surgery is usually combined with radiation therapy.
The major advantage of breast-conserving surgery is cosmetic: This surgery may help preserve body image. Thus, when the tumor is large in relation to the breast, this type of surgery is less likely to be useful. In such cases, removing the tumor plus some surrounding normal tissue means removing most of the breast. Breast-conserving surgery is usually more appropriate when tumors are small. In about 15% of women who undergo breast-conserving surgery, the amount of tissue removed is so small that little difference can be seen between the treated and untreated breasts. However, in most women, the treated breast shrinks somewhat and may change in contour.
Mastectomy is the other main surgical option. There are several types:
- Simple mastectomy consists of removing all breast tissue but leaving the muscle under the breast and enough skin to cover the wound. Reconstruction of the breast is much easier if these tissues are left. A simple mastectomy, rather than breast-conserving surgery, is usually performed when there is a substantial amount of cancer in the milk ducts.
- Modified radical mastectomy consists of removing all breast tissue and some lymph nodes in the armpit but leaving the muscle under the breast. This procedure is usually performed instead of a radical mastectomy.
- Radical mastectomy consists of removing all breast tissue plus the lymph nodes in the armpit and the muscle under the breast. This procedure is rarely performed now.
Lymph node surgery (lymph node dissection) is also performed if the cancer is or is suspected to be invasive. Nearby lymph nodes (usually about 10 to 20) are removed and examined to determine whether the cancer has spread to them. If cancer cells are detected in the lymph nodes, the likelihood that the cancer has spread to other parts of the body is increased. In such cases, additional treatment is needed. Removal of lymph nodes often causes problems, because it affects the drainage of fluids in tissues. As a result, fluids may accumulate, causing persistent swelling (lymphedema) of the arm or hand. Arm and shoulder movement may be limited. Other problems include temporary or persistent numbness, a persistent burning sensation, and infection.
 See the figure What Is a Sentinel Lymph Node?
A sentinel lymph node biopsy is an alternative approach that may minimize or avoid the problems of lymph node surgery. This procedure involves locating and removing the first lymph node (or nodes) into which the tumor drains. If this node contains cancer cells, the other lymph nodes are removed. If it does not, the other lymph nodes are not removed. Whether this procedure is as effective as standard lymph node surgery is being studied.
Breast reconstruction surgery may be performed at the same time as a mastectomy or later. A silicone or saline implant or tissue taken from other parts of the woman's body may be used. The safety of silicone implants, which sometimes leak, has been questioned. However, there is almost no evidence suggesting that silicone leakage has serious effects.
 See the figure Rebuilding a Breast.
Radiation Therapy: This treatment is used to kill cancer cells at the site from which the tumor was removed and in the surrounding area, including nearby lymph nodes. Side effects include swelling in the breast, reddening and blistering of the skin in the treated area, and fatigue. These effects usually disappear within several months, up to about 12 months. Fewer than 5% of women treated with radiation therapy have rib fractures that cause minor discomfort. In about 1% of women, the lungs become mildly inflamed 6 to 18 months after radiation therapy is completed. Inflammation causes a dry cough and shortness of breath during physical activity that last for up to about 6 weeks.
To improve radiation therapy, doctors are studying several experimental procedures. In one procedure, tiny radioactive seeds are inserted through a catheter to the tumor site. Radiation therapy can be completed in only 5 days. In another procedure, a tiny coil that emits radiation is implanted in the space left by the tumor. Radiation therapy can be completed in 25 minutes.
Drugs: Chemotherapy and hormone-blocking drugs are used to suppress the growth of cancer cells throughout the body. Chemotherapy and sometimes hormone-blocking drugs are used in addition to surgery and radiation therapy if cancer cells are detected in the lymph nodes and often if they are not. These drugs are often started soon after breast surgery and are continued for several months. Some, such as tamoxifen, may be continued for up to 5 years. These drugs delay the recurrence of cancer and prolong survival in most women.
Chemotherapy is used to kill rapidly multiplying cells or slow their multiplication. Chemotherapy alone cannot cure breast cancer; it must be used with surgery or radiation therapy. Chemotherapy drugs are usually given intravenously in cycles. Sometimes they are given by mouth. Typically, a day of treatment is followed by several weeks of recovery. Using several chemotherapy drugs together is more effective than using a single drug. The choice of drugs depends partly on whether cancer cells are detected in nearby lymph nodes. Commonly used drugs include cyclophosphamide, doxorubicin, epirubicin, fluorouracil, methotrexate, and paclitaxel (see Section 15, Chapter 182). Side effects (such as vomiting and nausea, hair loss, and fatigue) vary depending on which drugs are used. Chemotherapy can also cause infertility and early menopause by destroying the eggs in the ovaries.
Hormone-blocking drugs interfere with the actions of estrogen or progesterone, which stimulate the growth of cancer cells that have estrogen or progesterone receptors. These drugs may be used when cancer cells have these receptors. Tamoxifen, given by mouth, is the most commonly used estrogen-blocking drug. In women who have estrogen receptor-positive cancer, use of tamoxifen increases the likelihood of survival during the first 10 years after diagnosis by about 20 to 25%. Tamoxifen, which is related to estrogen, has some of the benefits and risks of estrogen therapy taken after menopause (see Section 22, Chapter 243). For example, it may decrease the risk of developing osteoporosis and it may increase the risk of developing cancer of the uterus (endometrial cancer). However, unlike estrogen therapy, tamoxifen may worsen the vaginal dryness or hot flashes that occur after menopause.
Biologic response modifiers are natural substances or slightly modified versions of natural substances that are part of the body's immune system. These drugs enhance the immune system's ability to fight cancer. They include interferons, interleukin-2, lymphocyte-activated killer cells, tumor necrosis factor, and monoclonal antibodies. Trastuzumab, a monoclonal antibody, is used to treat metastatic breast cancer only when the cancer cells have too many HER-2/neu receptors. This drug binds with HER-2/neu and thus prevents it from promoting the growth of cancer cells. Herceptin can cause heart problems by weakening the heart muscle. Other biologic response modifiers are sometimes tried experimentally as treatment for breast cancer (see Section 15, Chapter 182), but their role has not been established.
Tumor Ablation: In an experimental procedure called tumor ablation, doctors insert a multipronged probe into the tumor. Then a highly focused beam of light (laser), high-energy radio waves, or cold is used to destroy only the cancer cells.
See the table How Lymph Node Status Influences Survival.
Treatment of Noninvasive Cancer (Stage 0)
For ductal carcinoma in situ, treatment usually consists of a simple mastectomy or lumpectomy and sometimes radiation therapy.
For lobular carcinoma in situ, treatment is less clear-cut. For most women, the preferred treatment is close observation with no treatment. Observation consists of a physical examination every 6 to 12 months for 5 years and once a year thereafter plus mammography once a year. No treatment is usually needed. Although invasive breast cancer may develop (the risk is 1.3% per year or 26% for 20 years), the invasive cancers that develop are usually not fast growing and can usually be treated effectively. Furthermore, because invasive cancer is equally likely to develop in either breast, the only way to eliminate the risk of breast cancer for women with lobular carcinoma in situ is removal of both breasts (bilateral mastectomy). Some women, particularly those who are at high risk of developing invasive breast cancer, choose this option.
Alternatively, tamoxifen, a hormone-blocking drug, may be given for 5 years. It reduces but does not eliminate the risk of developing invasive cancer.
Treatment of Localized or Regional Invasive Cancer (Stages I through III)
For cancers that have not spread beyond nearby lymph nodes, treatment almost always includes surgery to remove as much of the tumor as possible and nearby lymph nodes or the sentinel lymph node.
A simple mastectomy is commonly used to treat invasive cancer that has spread extensively within the milk ducts (invasive ductal carcinoma), because this type of cancer often recurs when breast-conserving surgery is used. A modified radical mastectomy may also be used. A radical mastectomy, in which the underlying chest muscles and other tissues are also removed, does not improve life expectancy. Women who have had a simple or a modified radical mastectomy live as long as women who have had a radical mastectomy.
Whether radiation therapy, chemotherapy, or both are used after surgery depends on how large the tumor is and how many lymph nodes contain cancer cells. Sometimes, when the tumor is large, chemotherapy is given before surgery to reduce the size of the tumor. If chemotherapy reduces the size of the tumor, doctors can sometimes perform breast-conserving surgery rather than a mastectomy. After surgery and radiation therapy, additional chemotherapy is usually given, and women who have estrogen receptor-positive cancer are usually given tamoxifen.
Treatment of Cancer That Has Spread (Stage IV)
Breast cancer that has spread beyond the lymph nodes is rarely cured, but most women who have it live at least 2 years and a few live 10 to 20 years. Treatment extends life only slightly but may relieve symptoms and improve quality of life.
Initial treatment almost always includes surgery to remove the primary tumor, even though such removal is unlikely to cure cancer that has spread. If the cancer recurs in the breast after initial treatment, breast surgery is not usually repeated. Instead, radiation may be tried. However, surgery to remove tumors in other parts of the body (such as the brain) may be recommended, because such surgery can relieve symptoms.
Other treatments, such as chemotherapy, especially if they have uncomfortable side effects, are often postponed until a woman develops symptoms (pain or other discomfort) or the cancer starts to worsen quickly. Pain is usually treated with analgesics. Other drugs may be given to relieve other symptoms. Chemotherapy or hormone-blocking drugs are given to relieve symptoms and improve quality of life rather than to prolong life. The most effective chemotherapy regimens for breast cancer that has spread include capecitabine, cyclophosphamide, docetaxel, doxorubicin, epirubicin, gemcitabine, paclitaxel, and vinorelbine.
Hormone-blocking drugs are preferred to chemotherapy in certain situations. For example, these drugs may be preferred when the cancer is estrogen receptor-positive, when cancer has not recurred for more than 2 years after diagnosis and initial treatment, or when cancer is not immediately life threatening. Hormone-blocking drugs are especially effective for women in their 40s who are still menstruating and producing a lot of estrogen, as well as for those who are at least 5 years past menopause. However, these guidelines are not absolute. For women who are still menstruating, tamoxifen is usually the first hormone-blocking drug used because it has few side effects. For postmenopausal women who have estrogen receptor-positive breast cancer, aromatase inhibitors (such as anastrozole, letrozole, and exemestane) may be more effective as a first treatment than tamoxifen. These drugs inhibit the enzyme aromatase (which converts some hormones to estrogen), possibly reducing estrogen production. Progestins, such as medroxyprogesterone or megestrol, may be used instead of aromatase inhibitors and tamoxifen and have almost as few side effects. Fulvestrant, a new drug, may be used when tamoxifen is no longer effective. It destroys the estrogen receptors in cancer cells. The most common side effect is stomach upset. Alternatively, for women who are still menstruating, surgery to remove the ovaries, radiation to destroy them, or drugs to inhibit their activity may be used to stop estrogen production.
The monoclonal antibody trastuzumab can be combined with paclitaxel as initial treatment for breast cancer that has spread throughout the body. Trastuzumab can be combined with hormone-blocking drugs to treat women who have estrogen receptor-positive breast cancer. Sometimes trastuzumab can be used to treat women who do not respond to chemotherapy.
In some situations, radiation therapy may be used instead of or before drugs. For example, if only one area of cancer is detected in a bone, without any other evidence of recurrences, radiation to that bone might be the only treatment used. Radiation therapy is usually the most effective treatment for cancer that has spread to bone, sometimes keeping it in check for years. It is also often the most effective treatment for cancer that has spread to the brain.
Treatment of Specific Types of Breast Cancer
For inflammatory breast cancer, treatment usually consists of both chemotherapy and radiation therapy. Mastectomy is usually performed.
For Paget's disease of the nipple, treatment usually consists of a simple mastectomy and removal of the lymph nodes. Less commonly, the nipple with some surrounding normal tissue is removed.
For cystosarcoma phyllodes, treatment usually consists of wide excision mastectomy, in which the tumor and a large amount of surrounding normal tissue are removed. If the tumor is large in relation to the breast, a simple mastectomy may be performed. After surgical removal, about 20 to 35% of cancers recur near the same site.
Follow-up Care
After treatment is completed, follow-up physical examinations, including examination of the breasts, chest, neck, and armpit, are performed every 3 months for 2 years, then every 6 months for 5 years from the date the cancer was diagnosed. Regular mammograms and breast self-examinations are also important. A woman should report any changes in her breasts to her doctor immediately. Other symptoms should also be reported. They include pain, loss of appetite or weight, changes in menstruation, bleeding from the vagina (if not associated with the menstrual period), and blurred vision. Any symptoms that seem unusual or that persist should also be reported. Diagnostic procedures, such as chest x-rays, blood tests, bone scans, and computed tomography (CT), are not needed unless a woman has symptoms suggesting recurrence of the cancer.
The effects of treatment for breast cancer cause many changes in a woman's life. Support from family members and friends can help, as can support groups. Counseling may be helpful.
End-of-Life Issues
For a woman with metastatic breast cancer, quality of life may deteriorate and the possibilities for further treatment may become limited. Staying comfortable may eventually become more important than trying to prolong life. Cancer pain can be adequately controlled with appropriate drugs (see Section 1, Chapter 8). So if a woman is having pain, she should ask her doctor for treatment to relieve it. Psychologic and spiritual counseling may also help.
A woman with metastatic breast cancer should prepare advance directives indicating the type of care she desires in case she is no longer able to make such decisions (see Section 1, Chapter 9). Also, making or updating a will is important.
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