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Taking Charge: How Is Breast Cancer Treated?

The breast cancer mortality rate — the number of breast cancer deaths per 100,000 women — has declined in the past decade, most likely due to new, more effective treatments and increased screening of women leading to early detection.

Treatment options may include the following:

Surgery

Your breast surgeon may remove the tumor in one of several ways. A lumpectomy removes only the lump and a surrounding margin of normal tissue. Women who undergo lumpectomy almost always undergo 6 to 7 weeks of radiation therapy of the breast to kill any cancer cells that were left behind.

A total mastectomy is surgical removal of the breast, including as much breast tissue as possible, the nipple and some of the overlying skin. A partial mastectomy removes more breast tissue than a lumpectomy, but not as much as a total mastectomy. A modified radical mastectomy is a more extensive operation that removes not only the entire breast, but also lymph nodes under the arm (axillary nodes). A radical mastectomy, which removes chest wall muscles as well as the breast and axillary lymph nodes used to be a common form of surgery, but it is rarely performed anymore.

Lymph Node Removal

No matter what type of breast surgery you have, your doctor will usually remove some of the lymph nodes under your armpit, a procedure called a lymph node dissection. These armpit (axillary) nodes sometimes contain cancer cells.

Knowing whether the axilliary nodes are involved, or "positive" for cancer, helps your doctor determine whether your cancer is likely to have spread beyond the breast, and which additional treatments, such as chemotherapy, are most likely to help you.

Sentinel Lymph Node Biopsy

Another way to decide whether cancer is present in the lymph nodes is to perform a sentinel lymph node biopsy. During surgery to remove your cancer, a radioactive tracer and/or a blue dye is injected into the region of the tumor. The surgeon then watches to see which lymph node is the first to receive the dye or tracer as it is carried away from the tumor site by the lymphatic vessels. The surgeon then removes this "sentinel" node. If it is free of cancer, your doctor may not need to remove any other lymph nodes.

This procedure is still quite new, but many doctors believe that it will prove to be as effective as axillary dissection in at least some patients. This could be important because removal of the lymph nodes produces a condition called lymphedema (swelling of the arm) in 10 percent to 20 percent of women with breast cancer. It is hoped that decreasing the amount of surgery performed in the armpit will decrease lymphedema and other side effects.

Breast Reconstruction

Many women choose to have a plastic surgeon reconstruct their breast, either at the time of mastectomy or afterward. The surgeon may use saline-filled implants, tissue from other parts of the body, or both to rebuild a natural looking breast and nipple.

Reconstruction should be discussed with a plastic surgeon before you have your mastectomy. California law requires that insurers cover the costs of breast reconstruction.

Breast Forms

Some women use breast forms, also called a breast prosthesis, instead of having their breast reconstructed surgically. The prosthesis, which is made of a soft synthetic material, is fitted after your incision has healed. You may be able to use the prosthesis with your old bra, or you may want to use a special mastectomy bra. Many department and specialty stores can help you with obtaining a comfortably fitting form and bra.

Expenses for breast forms and bras may be tax deductible. Insurers often pay for breast forms and mastectomy bras, but may not pay for subsequent reconstructive surgery if you submit a claim for prosthetic equipment. Check details with your insurance company first.

Chemotherapy

Treatment with anti-cancer drugs is called chemotherapy. Chemotherapy drugs may be given intravenously — injected into a vein — or by mouth. Chemotherapy is designed to kill cancer cells that have traveled to distant parts of the body, and its use has been shown to reduce the risk of breast cancer recurrence.

A combination of several drugs is generally used. The most common combinations are cyclophosphamide, methotrexate and fluorouracil (CMF), cyclophosphamide, doxorubicin (Adriamycin) and fluorouracil (CAF), and doxorubicin (Adriamycin) and cyclophosphamid (AC). Taxol may also be used.

Chemotherapy is given in cycles, with a recovery period in between. A complete course of chemotherapy typically lasts from three to six months.

In addition to killing cancer cells, chemotherapeutic drugs can damage normal cells that grow rapidly in the body. For this reason, you may experience fatigue, nausea, vomiting, diarrhea, constipation, weight change, mouth sores and throat soreness, or hair loss during your chemotherapy. Your doctor can prescribe remedies for many of these temporary side effects. Several drugs can prevent or reduce nausea and vomiting, for example. Permanent effects that may occur, especially in older women, include premature menopause and infertility. In very rare instances, more serious side effects occur.

Hormonal Therapy

If the tests that the pathologist performs on your tumor indicate that the breast cancer cells are sensitive to female hormones (estrogen or progesterone receptor-positive), your doctor may recommend that you take a hormone blocker. This is a drug that prevents your body's natural hormones from reaching the cancer and encouraging its growth. The most commonly prescribed drug for this purpose is tamoxifen. Another drug, called raloxifene, is currently under study.

Most women do not experience any significant side effects from use of these drugs, but you should be carefully monitored by your physician while you take them.

Radiation Therapy

Radiation therapy, administered to the breast, is usually given to kill any remaining cancer cells after a woman undergoes a lumpectomy. The treatment is given in the outpatient department of a hospital. Treatments are usually scheduled five days a week for 5 to 6 weeks. In treatment planning, your chest is marked with a long-lasting ink so that the technicians who perform the therapy know where to aim the radiation.

Side effects can include swelling and heaviness in the breast, skin changes that resemble sunburn, and tiredness. The changes usually go away in 6 to 12 months, although some women do notice a permanent change in the size, shape, or skin color of the breast.

Special Treatments for Advanced Disease

Women who have been treated with high doses of chemotherapy or radiation sometimes undergo bone marrow transplantation. This complex procedure replaces blood-producing cells in the bone marrow, which are often damaged from intensive cancer therapy.

Many kinds of experimental treatments may also be offered through clinical trials, which are studies of how new therapies work in patients.

What Is Staging?

Staging means finding out how much cancer you have and whether it has spread (metastasized) to other places in your body. To obtain this information, your doctor will send a sample of the tumor to a pathologist for testing.

The pathologist will determine the grade of your tumor, which is a measure of how abnormal the cells look under a microscope, compared to normal cells. The sample will also be tested to see if the tumor cells have receptors that make them sensitive to estrogen and progesterone — in other words, whether they are "receptor positive." These hormones are important in the development of breast cancer. If receptors are present, it may be possible to treat the cancer with hormonal therapy. The pathologist may also test for cancer-causing genes (oncogenes), including one called HER2, in the abnormal cells.

Breast cancer is classified according to stage 0 through stage IV. Stage 0 is non-invasive cancer; stage IV cancer is a tumor that has spread to other organs of the body. The other stages describe tumors that are somewhere in between. In determining the stage of your cancer, doctors consider both the size of the tumor and evidence that it has spread to the lymph nodes under the armpit or to the chest wall.

For more information, please see Breast Cancer Staging.

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Reviewed by health care specialists at UCSF Medical Center.

This information is for educational purposes only and is not intended to replace the advice of your doctor or health care provider. We encourage you to discuss with your doctor any questions or concerns you may have.

Related Information

UCSF Clinics & Centers

Breast Care

Helen Diller Family Comprehensive Cancer Center

Gynecologic Surgical Oncology
1600 Divisadero St., Fourth Floor
San Francisco, CA 94115
Phone: (415) 353-9600
New Patient Fax: (415) 353-7657

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