BreastCancer

What is breast cancer?

Breast cancerstarts whencells in thebreast begin to grow out of control. These cells
usuallyform atumorthatcan often beseen onan x-rayorfelt as alump. Thetumoris
malignant (cancerous)ifthe cells cangrow into (invade)surroundingtissues orspread
(metastasize)to distant areas ofthebody. Breast canceroccurs almost entirelyin women,
but men canget it, too.
Cells in nearlyanypart ofthebodycan becomecancer, andcan spread to other areas of
thebody. To learn moreabout how all cancers start and spread, seeWhat Is Cancer?
This informationrefersonly to breast cancerinwomen. Forinformationon breast
cancerinmen, seeBreast Cancer in Men.
Breast cancerscan startfrom different parts ofthebreast. Most breast cancers begin in
theducts that carrymilk to thenipple (ductal cancers). Somestart in theglands that make
breast milk (lobularcancers). Therearealso othertypes ofbreastcancerthat areless common.
A small numberof cancers start in othertissues in thebreast. Thesecancersarecalled
sarcomas and lymphomas and arenot reallythought of as breastcancers.
Although manytypes ofbreast cancer cancausealump in thebreast, not all do. There
areothersymptoms ofbreast canceryou should watch out for andreport toahealth care
provider.
Itsalso important to understand that most breast lumps arenot cancer, theyarebenign.
Benign breast tumors areabnormalgrowths, but theydo not spread outsideofthebreast and
theyarenot lifethreatening.But somebenignbreast lumps can increaseawoman's risk
ofgettingbreast cancer. Anybreast lump orchangeneeds to be checked byahealth
careproviderto determinewhetherit is benign orcancer, and whetherit might impact
yourfuturecancer risk.Formoreinformation seeWhat aretherisk factors forbreast
cancer? and Non-cancerous Breast Conditions.

HowBreastCancerSpreads
Breastcancer canspreadthroughthelymphsystem.
Thelymphsystemincludeslymphnodes,lymphvesselsandlymphfluidfound
throughoutthebody.Lymphnodesaresmall,bean-shapedcollectionsofimmunesystem
cellsthat areconnectedbylymph(orlymphatic)vessels.Lymphvesselsarelikesmall
veins,exceptthat theycarrya clearfluidcalledlymph(insteadofblood)awayfromthe
breast.Lymphcontainstissuefluidandwasteproducts,aswell asimmunesystemcells.
Breastcancer cells can enterlymphvesselsandbegintogrowinlymphnodes.
Mostofthelymphvesselsofthebreastdraininto:
Lymphnodesunderthearm(axillarynodes).
Lymphnodesaroundthecollarbone(supraclavicularandinfraclavicularlymph
nodes)

Lymph nodes insidethechest nearthebreast bone (internalmammary lymph

nodes)

Ifcancercells havespread toyourlymph nodes, thereis ahigher chancethat the cells could
havespread (metastasized)to othersites in yourbody. Themorelymph nodes with breast
cancer cells, themorelikelyit is that thecancermaybe found in otherorgansas well.
Becauseofthis, findingcancerin oneormorelymph nodes often affectsyour treatment plan.
Usually,surgeryto removeoneormorelymph nodeswill beneeded to know whetherthe
cancerhas spread there.
Still, not all women withcancercells in theirlymph nodes develop metastases, and some
women can haveno cancer cells in theirlymph nodes and laterdevelop metastases.

Types of breast cancers

Breast cancercan beseparated into different types based on thewaythe cancercells look
underthemicroscope.
Most breast cancersarecarcinomas, atypeofcancerthat starts in thecells (epithelial
cells)that lineorgansand tissues likethebreast.In fact, breast cancers areoften atypeof
carcinomacalled adenocarcinoma, which is carcinomathat starts in glandulartissue.
Othertypes ofcancers can occurin thebreast, too,such as sarcomas, whichstart in the cells
ofmuscle, fat, or connectivetissue.
In somecasesasinglebreast tumor can bea combination ofdifferent types orbea
mixtureofinvasive and in situ cancer.And in some rarertypes ofbreast cancer, the
cancercells maynot form atumor at all.
Breast cancercanalso beclassified based on proteins on orin the cancercells, into groups
likehormone receptor-positiveortriple-negative. Thesearediscussed in How is breast
cancer classified?

Ductalcarcinomainsitu
Ductal carcinomain situ (DCIS; also knownas intraductal carcinoma)is considered noninvasiveorpre-invasivebreast cancer. DCISmeans that cells that lined theducts have
changed to look likecancer cells. Thedifferencebetween DCISand invasive canceris
that the cells havenot spread (invaded)through thewalls oftheducts into the
surroundingbreast tissue. Becauseit hasnt invaded, DCIScant spread (metastasize)
outsidethebreast. DCISis considered apre-cancerbecausesomecases cango on to
becomeinvasivecancers.Right now, though, thereis no good wayto knowfor certain
which caseswill go on tobecomeinvasivecancersand which ones wont.

About 1 in 5 new breast cancercases will beDCIS. Nearlyall women diagnosed at this
earlystageofbreast cancer can be cured.

Invasive(orinfiltrating)ductalcarcinoma
This is themost commontypeofbreast cancer.Invasive (orinfiltrating)ductal carcinoma
(IDC)starts in amilk duct ofthebreast, breaks through thewall oftheduct, and grows into
the fattytissueofthebreast. At this point, it maybe ableto spread (metastasize)to otherparts
ofthebodythrough thelymphaticsystem and bloodstream. About 8 of10 invasivebreast
cancers areinfiltratingductal carcinomas.

Invasive(orinfiltrating)lobularcarcinoma
Invasivelobularcarcinoma(ILC)starts in themilk-producing glands (lobules).LikeIDC, it
can spread(metastasize)to otherparts ofthebody. About 1 in 10 invasivebreast cancers is
anILC.Invasivelobular carcinomamaybeharderto detect byamammogram than
invasiveductal carcinoma.

Lesscommontypesofbreastcancer
Inflammatorybreast cancer
This uncommon typeofinvasivebreast canceraccounts for about 1%to 3%of all breast
cancers. Usuallythereis no singlelump ortumor.Instead, inflammatorybreast cancer
(IBC)makes theskin onthebreast look redand feel warm.It also may givethebreast
skin athick, pitted appearancethat looks alot like an orangepeel. Doctorsnow know that
these changes arenot caused byinflammation orinfection, but bycancercells blocking
lymph vessels in theskin. The affected breast maybecomelargerorfirmer,tender, or itchy.

In its earlystages, inflammatorybreast canceris often mistaken foran infection in the

breast (called mastitis)and treated asan infection with antibiotics.Ifthesymptoms are
caused bycancer, theywill not improve, and abiopsywill find cancercells. Because
thereis no actual lump, itmight not show up on amammogram, which canmakeit even
harderto find it early. This typeofbreast cancertends to haveahigherchanceof
spreadingandaworseoutlook (prognosis)than typical invasiveductal orlobular cancer.
Formoredetails about this condition, seeInflammatoryBreast Cancer.

Paget diseaseof thenipple

This typeofbreast cancerstarts in thebreast ducts and spreads to theskin ofthenipple and
then to the areola, thedark circlearound thenipple.It is rare,accountingforonly about 1%of
all cases ofbreast cancer. Theskin ofthenipple and areolaoften appears crusted, scaly,and
red, with areas ofbleedingoroozing. Thewoman maynoticeburning oritching.
Paget diseaseis almost always associated with eitherductal carcinomain situ (DCIS)or
infiltratingductal carcinoma. Treatment often requires mastectomy.Ifno lump can befelt in
thebreast tissue, and thebiopsyshows DCISbut no invasive cancer, theoutlook
(prognosis)is excellent.Ifinvasive canceris present, theprognosis is not asgood, and
the cancerwill need to bestaged and treated likeanyotherinvasivecancer.

Phyllodestumor
This veryrarebreast tumordevelops in thestroma(connectivetissue)ofthebreast, in
contrast to carcinomas, which develop in theductsorlobules. Othernamesforthese
tumors includephylloides tumor and cystosarcoma phyllodes. Thesetumors areusually
benign but on rareoccasions maybemalignant.
Benign phyllodes tumorsaretreated byremoving thetumor alongwith amargin of normal
breast tissue. Amalignant phyllodes tumoris treated byremoving it alongwith a
widermargin ofnormal tissue, orbymastectomy.Surgeryis often all that is needed, but
these cancers might not respond as well to theothertreatments used formore common
breast cancers. When amalignant phyllodes tumorhas spread, it can betreated with the
chemotherapy given forsoft-tissuesarcomas. SeeSarcoma:Adult Soft TissueCancer.

Angiosarcoma
This form of cancerstarts in cells that lineblood vessels orlymph vessels.It rarely occurs
in thebreasts. When it does, it usuallydevelops as a complication ofprevious radiation
treatments. This is an extremelyrarecomplication ofbreast radiation therapy that can
develop about 5to 10years afterradiation. Angiosarcomacan also occurin the arms
ofwomen who develop lymphedema as aresult oflymph nodesurgeryor radiation
therapyto treat breastcancer. (Forinformation on lymphedema, see"Howis breast
cancertreated?")These cancers tend to grow and spread quickly. Treatmentis generally
thesame as forothersarcomas. SeeSarcoma:Adult Soft TissueCancer.

Specialtypesofinvasivebreastcarcinoma
Therearesomespecial types ofbreast cancerthataresub-types ofinvasivecarcinoma.
These areoften named after features seen when theyareviewed underthemicroscope,
liketheways thecells are arranged.

Someofthesemayhaveabetterprognosis than standard infiltratingductalcarcinoma.

Theseinclude:
Adenoid cystic (oradenocystic) carcinoma
Low-grade adenosquamous carcinoma(this is atypeofmetaplasticcarcinoma)
Medullarycarcinoma
Mucinous (or colloid) carcinoma
Papillarycarcinoma
Tubular carcinoma
Somesub-types havethesameormaybeworseprognosis than standard infiltratingductal
carcinoma.Theseinclude:
Metaplastic carcinoma(most types, includingspindle cell and squamous)
Micropapillarycarcinoma
Mixed carcinoma (has features ofboth invasiveductal and lobular)
Ingeneral, all ofthesesub-typesarestill treated likestandard infiltratingductal
carcinoma.

What are thekeystatistics about breast

cancer?
Breast canceris themostcommon cancer among American women, except forskin
cancers. About 1 in 8 (12%)women in theUSwill develop invasivebreastcancerduring
theirlifetime.
Apa statistik kunci tentang payudara kanker?
Kanker payudara adalah kanker yang paling umum di kalangan wanita Amerika, kecuali
untuk kulit kanker. Sekitar 1 dari 8 (12%) wanita di Amerika Serikat akan
mengembangkan kanker payudara invasif selama seumur hidup mereka.

Currentyearestimatesforbreastcancer
TheAmerican CancerSociety'sestimates forbreast cancerin theUnited States for2016 are:
About 246,660 new cases ofinvasivebreast cancerwill bediagnosed in women.
About 61,000 new casesof carcinomain situ (CIS)will bediagnosed (CISis noninvasive and is the earliest form ofbreast cancer).
About 40,450 women will die from breastcancer.
Perkiraan tahun berjalan untuk kanker payudara Perkiraan American Cancer Society untuk
kanker payudara di Amerika Serikat untuk 2016 adalah: Tentang 246.660 kasus baru kanker
payudara invasif akan didiagnosis pada wanita. Tentang 61.000 kasus baru karsinoma in situ
(CIS) akan didiagnosis (CIS adalah non-invasif dan adalah bentuk paling awal dari kanker
payudara). Tentang 40.450 wanita meninggal akibat kanker payudara.

Trendsinbreastcancerincidence
Afterincreasingformorethan 20years, breast cancerincidencerates in women began
decreasingin 2000, anddropped byabout 7%from 2002 to 2003. This largedecrease
was thought to bebecause fewerwomen used hormonetherapyaftermenopause afterthe
results oftheWomen's HealthInitiativewerepublished in 2002. This studylinked using
hormonetherapytoan increased risk ofbreast cancer and heart diseases.
Inrecentyears, incidencerates havebeen stablein whitewomen, but haveincreased
slightlyin African American women.

Trendsinbreastcancerdeaths
Breast canceris thesecond leading causeofcancerdeath in women.(Onlylungcancer kills
morewomen eachyear.)The chancethat awoman will die from breast canceris about 1
in 36 (about 3%).
Death rates from breast cancerhavebeen droppingsinceabout 1989, with larger decreases
in womenyoungerthan 50. Thesedecreases arebelieved to bethe result of findingbreast
cancer earlierthrough screeningandincreased awareness, aswell as better treatments.

Breastcancersurvivors
At this timethere aremorethan 2.8 million breastcancersurvivors in theUnited States.
(This includes women still beingtreated and thosewho havecompleted treatment.)
Survival rates arediscussed in Breast cancersurvival rates, bystage.
Visit theAmerican CancerSocietys CancerStatistics Center formorekeystatistics.
Tren kejadian kanker payudara
Setelah meningkat selama lebih dari 20 tahun, kanker payudara tingkat insiden
pada wanita mulai
menurun pada tahun 2000, dan turun sekitar 7% dari tahun 2002 ke 2003.
Penurunan besar ini
dianggap karena lebih sedikit wanita menggunakan terapi hormon setelah
menopause setelah
Hasil Perempuan Health Initiative diterbitkan pada tahun 2002. Penelitian ini
terkait dengan
terapi hormon dengan peningkatan risiko kanker payudara dan penyakit
jantung.
Dalam beberapa tahun terakhir, tingkat insiden telah stabil pada wanita kulit
putih, namun telah meningkat
sedikit pada perempuan Afrika Amerika.
Tren kematian akibat kanker payudara
Kanker payudara adalah penyebab utama kedua kematian akibat kanker pada
wanita. (Hanya kanker paru-paru
membunuh lebih banyak perempuan setiap tahun.) Kemungkinan bahwa
seorang wanita akan meninggal akibat kanker payudara adalah
sekitar 1 di 36 (sekitar 3%).
Tingkat kematian dari kanker payudara telah menurun sejak sekitar tahun
1989, dengan lebih besar
menurun pada wanita yang lebih muda dari 50. penurunan ini diyakini hasil

menemukan kanker payudara sebelumnya melalui screening dan peningkatan

kesadaran, serta lebih baik
perawatan.
kanker payudara
Saat ini ada lebih dari 2,8 juta penderita kanker payudara di Amerika Serikat.
(Ini termasuk perempuan masih dirawat dan mereka yang telah menyelesaikan
pengobatan.)
tingkat ketahanan hidup yang dibahas dalam "tingkat kelangsungan hidup
kanker payudara, dengan panggung."
Kunjungi American Cancer Society Cancer Statistik Pusat statistik yang lebih
utama.

What are therisk factorsfor breast cancer?

Most women who haveoneormorebreast cancerrisk factors neverdevelop breast
cancer, whilemanywomen with breast cancerhaveno known risk factors (otherthan
being awoman andgrowingolder). Even when awoman with risk factorsdevelops
breast cancer, its hard toknow just how much these factors might have contributed.
Some risk factors, likeaperson's ageor race,can'tbe changed. Otherrisk factors are linked
to cancer-causing factors in the environment orto personal behaviors, such as smoking,
drinking,and diet. Some factors affect risk morethan others, andyourrisk for breast
cancer canchangeovertime, dueto things likeagingorlifestyle.

Breastcancerriskfactors youcannotchange
Themain risk factors forbreast cancer arethingsyou cannot change: being awoman,
gettingolder,and having certaingene changes. Thesemakeyour risk ofbreast cancer
higher.But having a riskfactor, oreven many, does not mean thatyouaresureto get the
disease.

Beingawoman
Simplybeing awoman isthemain risk factorforbreast cancer. Men can havebreast cancer,
too, but this diseaseis about 100 times more common in women than in men. This might
bebecausemen haveless ofthe femalehormones estrogen andprogesterone, which can
promotebreast cancer cellgrowth.

Gettingolder
Asyouget older,your risk ofbreast cancergoes up. Most invasivebreast cancers(those that
havespread from wheretheystarted)arefound in women age55 and older.

Certain inherited genes

About 5%to 10%ofbreast cancercases arethought to behereditary, meaningthat they
result directlyfromgenedefects (called mutations)passed on from aparent.
BRCA1 and BRCA2:Themost common causeofhereditarybreast canceris an inherited
mutation in theBRCA1 and BRCA2genes.In normal cells, thesegenes help prevent
cancerbymakingproteins that help keepthe cells fromgrowing abnormally. Mutated
versions ofthesegenes cannot stop abnormal growth, and that can lead to cancer.
Ifyou haveinherited amutated copyof eithergene from aparent,you haveahigher risk
ofbreastcancer.
In somefamilies with BRCA1 mutations thelifetime risk ofbreast canceris as high as
80%, but on averagethis risk seems to bein the rangeof55%to 65%.ForBRCA2
mutations the risk is lower, around 45%.
Breast cancers linked to thesemutations aremoreoften found inyounger women and
moreoften in both breasts than cancers not linkedto thesemutations. Women with
theseinherited mutations also haveahigher risk ofdevelopingothercancers, mainly
ovarian cancer.
In theUnited States, BRCA mutations aremorecommon inJewish peopleof Ashkenazi
(Eastern Europe)origin than in otherracial andethnicgroups,but anyone can
havethem.

Changes inothergenes:Othergenemutations can also lead to inherited breast cancers.

Thesegenemutations aremuch less common andmost ofthem do not increasetherisk of
breast cancer as muchas theBRCAgenes. Theyareseldom causes ofinherited breast cancer.
ATM:TheATMgenenormallyhelps repairdamagedDNA.Inheriting2abnormal copies
ofthis genecauses thediseaseataxia-telangiectasia.Inheritingoneabnormal copyofthis
genehas been linked to ahigh rateofbreast cancerin some families.
TP53:TheTP53genegives instructions formakingaprotein called p53 that helps stop
thegrowth of abnormal cells.Inherited mutations ofthis genecauseLi-Fraumeni
syndrome. Peoplewith this syndromehave an increased risk ofbreastcancer, as well as
someothercancers such as leukemia, brain tumors, and sarcomas (cancers of
bonesor connectivetissue). This mutation is a rare causeofbreast cancer.
CHEK2:Li-Fraumeni syndrome canalso becaused byinherited mutations in the
CHEK2 gene. A CHEK2 mutation, even when it doesnt causethis syndrome, can
increasebreast cancerrisk about 2-fold.
PTEN:ThePTENgenenormallyhelps regulate cell growth.Inherited mutations in this
genecauseCowden syndrome, araredisorderthat puts people at higherrisk for both noncancer andcancertumors in thebreasts,as well asgrowths in thedigestive tract, thyroid,
uterus, andovaries. Defects in this genecan also causeadifferent syndromecalled
Bannayan-Riley-Ruvalcaba syndromethats not thought to belinked to breast
cancerrisk. Thesyndromescaused bymutations in PTENcan begrouped together as
PTEN Tumor Hamartoma Syndrome.
CDH1:Inherited mutations in this genecausehereditarydiffusegastric cancer, a
syndromein which peopledevelop araretypeof stomach cancer. Womenwith
mutations in this gene also have an increased riskofinvasivelobularbreastcancer.
STK11:Defects in this genecan lead to Peutz-Jeghers syndrome. Peopleaffected
with this disorderhavepigmented spots on theirlips and in theirmouths, polyps in
theurinaryandgastrointestinal tracts, and ahigher risk ofmanytypes ofcancer,
includingbreast cancer.
PALB2:ThePALB2 genemakes aprotein that interacts with theprotein madebythe
BRCA2 gene. Mutations in this genecan lead to ahigherrisk ofbreast cancer.It isnt
yetclearifPALB2 genemutations also increasethe risk forovarian cancerand
malebreast cancer.
Formoreon this, see FamilyCancer Syndromes.
Genetic testing:Genetictestingcan bedoneto look formutations in theBRCA1 and
BRCA2 genes (orless commonlyin othergenes such as PTENorTP53).Whiletesting can
behelpful in some cases, thepros and cons need to be considered carefully.

Ifyourethinkingaboutgenetictesting, its stronglyrecommended thatyou first talk to a

genetic counselor, nurse,ordoctorwho can explain and interpret theresults ofthesetests. Its
veryimportant to understand whatgenetictestingcanand cant tellyou, and to
carefullyweigh thebenefits and risks ofgenetictestingbeforethesetests aredone.
Testingcosts alot and might not be covered bysomehealth insuranceplans.
Formore, see GeneticTesting:What You Need to Know.

Havingafamilyhistory of breast cancer

Its important to notethatmost women (about 8 out of10)whoget breast cancerdo not
haveafamilyhistoryofthedisease, but:
Women who have closeblood relatives with breast cancerhaveahigherrisk ofthe
disease.
Having a first-degree relative (mother, sister, ordaughter)with breast cancer almost
doubles awomans risk.Having2first-degreerelatives increases herrisk about 3- fold.
Women with a fatherorbrotherwho havehad breast cancer also haveahigher risk of
breast cancer.
Overall, less than 15%ofwomen with breast cancerhaveafamilymemberwith this
disease.

Havingapersonalhistoryof breast cancer

A woman with cancerinonebreast has ahigherrisk ofdevelopinganew cancerin the
otherbreast orin anotherpart ofthesamebreast. (This is different fromarecurrenceor return
ofthefirst cancer.)This risk is even higherforyoungerwomen withbreast cancer.

Your race and ethnicity

Overall, whitewomenareslightlymorelikelyto develop breast cancerthan AfricanAmerican women, but African-Americanwomen aremorelikelyto dieofthis cancer.In
women under45years ofage, breast canceris more common in African-American women.
Asian, Hispanic,and NativeAmerican women havealower risk ofdeveloping and dying
from breast cancer.

Havingdense breasttissue
Breasts aremadeup offattytissue, fibrous tissue,and glandulartissue. Someoneis said to
havedensebreasts (onamammogram)when theyhavemoreglandularand fibrous tissue and
less fattytissue. Women with densebreasts on mammogram havea risk of

breast cancerthat is 1.2 to 2 times that ofwomen with averagebreast density.

Unfortunately, densebreast tissue can also makemammograms lessaccurate.
A numberoffactorscanaffect breast density, such as age, menopausal status, theuseof
certain drugs(including menopausal hormonetherapy), pregnancy,andgenetics.
Formoreon this seeBreast Densityand Your Mammogram Report.

Certain benign breast conditions

Women diagnosed with certain benign (non-cancer)breast conditions mayhaveahigher
risk ofbreastcancer. Someofthese conditions aremore closelylinked tobreast cancer risk
than others. Doctorsoften dividebenign breast conditions into 3 general groups,
dependingon how theyaffect this risk.
Non-proliferativelesions:These conditions arelinked to an overgrowth ofbreast tissue.
Theydont seem to affect breast cancerrisk, oriftheydo, its to averysmall extent.
Theyinclude:
Fibrosis and/orsimplecysts (sometimes called fibrocystic changes ordisease)
Mild hyperplasia
Adenosis (non-sclerosing)
Phyllodes tumor (benign)
A singlepapilloma
Fat necrosis Duct
ectasia Periductal
fibrosis
Squamous and apocrinemetaplasia
Epithelial-relatedcalcifications
Otherbenign tumors (lipoma, hamartoma, hemangioma, neurofibroma,
adenomyoepthelioma)
Mastitis (infection ofthebreast)is not atumor anddoes not increasethe risk ofbreast
cancer.
Proliferativelesions withoutatypia (cell abnormalities):In these conditions theres
excessivegrowth ofcells in theducts orlobules ofthebreast. Theyseem toraisea
womans risk ofbreast cancerslightly. Theyinclude:

Usual ductal hyperplasia(without atypia)

Fibroadenoma
Sclerosing adenosis
Several papillomas (called papillomatosis)
Radial scar
Proliferativelesions withatypia:In theseconditions, thecells in theducts orlobules of
thebreast tissuegrowexcessively, and someofthem no longerlook normal. Thesetypes
oflesions include:
Atypical ductal hyperplasia (ADH)
Atypical lobularhyperplasia (ALH)
Breast cancerrisk is raised in women with thesechanges.Ifawoman has afamilyhistory
ofbreast cancer andeitherhyperplasiaor atypicalhyperplasia, shehas an even higher
risk ofbreastcancer.
Formoreon these conditions, seeNon-cancerousBreast Conditions.
Lobular carcinoma insitu:In lobular carcinomain situ (LCIS), cells thatlook like
cancercells aregrowing in thelobules ofthemilk-producing glands ofthebreast, but
theydo notgrow throughthewall ofthelobules.LCISis also called lobular neoplasia. Its
sometimesgroupedwith ductal carcinomain situ (DCIS) asanon-invasivebreast cancer,
but it differsfrom DCISin that it doesnt seem to becomeinvasive cancerifit isnt
treated.
Women with lobular carcinomain situ (LCIS)haveamuch higherrisk ofdeveloping
cancerin eitherbreast.

Startingmenstruation (periods) beforeage 12

Women who havehad moremenstrual cycles becausetheystarted menstruatingearly
(beforeage12)haveaslightlyhigher risk ofbreast cancer. Theincreasein risk maybe dueto
alongerlifetimeexposureto thehormones estrogen and progesterone.

Goingthrough menopauseafter age 55

Women who havehad moremenstrual cycles becausetheywent throughmenopauselater
(afterage55)haveaslightlyhigher risk ofbreastcancer. Theincreasein risk may
becausetheyhavealongerlifetime exposureto thehormones estrogen andprogesterone.

Havingradiation toyour chest

Women who as childrenoryoung adults weretreated with radiation therapyto the chest
for anothercancer(suchas Hodgkin diseaseornon-Hodgkin lymphoma)havea
significantlyhigherrisk forbreast cancer. This varies with thepatients agewhen they got
radiation. And ifyouhad chemotherapywith the radiation, it might havestopped
ovarian hormoneproduction forsometime, whichlowers the risk. Therisk ofdeveloping
breast cancer from chestradiation is highest ifyouhad radiation duringadolescence,
whenyourbreasts werestill developing. Radiation treatment afterage40 does not seem
to increasebreastcancerrisk.
Formoreinformation, seeSecond Cancers Caused byCancerTreatment.

Exposure todiethylstilbestrol(DES)
From the1940s through the early1970s somepregnant women weregivenan estrogenlikedrug called DESbecauseit was thought to lowertheirchances oflosingthebaby
(miscarriage). Thesewomen haveaslightlyincreased risk ofdevelopingbreast cancer.
Women whosemothers took DESduringpregnancymayalso haveaslightlyhigherrisk
ofbreast cancer.
FormoreonDESseeDES Exposure:Questions and Answers.

Lifestyle-relatedbreastcancerriskfactors
Certain breastcancer riskfactors arerelated to personal behaviors, suchasdiet and
exercise. Otherlifestyle-related risk factors includedecisions about having children and
takingbirth control.

Drinking alcohol
Drinking alcohol is clearlylinked to an increased risk ofdevelopingbreastcancer. The risk
increases with theamount of alcohol consumed. Compared with non-drinkers, women
who have1alcoholicdrink adayhaveaverysmall increasein risk. Thosewho have2 to 5
drinks dailyhave about 1 times the risk ofwomen who dontdrink alcohol. Excessive
alcohol consumption is known to increasethe risk ofother cancers, too.
TheAmerican CancerSocietyrecommends that women haveno morethan1 alcoholic
drink aday. A drink is 12 ounces ofregularbeer,5 ounces ofwine, or1.5ounces of80proofdistilled spirits.

Beingoverweight orobese
Beingoverweight orobese aftermenopauseincreases breast cancerrisk. Before
menopauseyourovariesmakemost ofyour estrogen, and fat tissuemakesonlyasmall
amount. Aftermenopause (when theovaries stopmakingestrogen), most ofawomans
estrogen comesfrom fat tissue. Havingmorefat tissue aftermenopausecanraise estrogen
levels and increaseyour chanceofgettingbreast cancer. Also, women who are overweight
tend to havehigherblood insulin levels. Higherinsulin levelshavebeen linked to some
cancers, includingbreast cancer.
Still, thelink between weight and breastcancer risk is complex. Forinstance, risk appears
to beincreased forwomen whogained weight asan adult, but maynot be increased
amongthosewho havebeen overweight since childhood. Also, excess fat in the waist
areamayaffect risk morethan thesameamount of fat in thehips and thighs. Researchers
believethatfat cells in various parts ofthebodyhavesubtledifferences that mayexplain this.
TheAmerican CancerSocietyrecommendsyou stayat ahealthyweight throughoutyour
lifebybalancingyourfood intakewith physical activityand avoidingexcessiveweight gain.

Physicalactivity
Evidenceisgrowingthatphysicalactivityin the form of exercisereduces breast cancer risk.
Themain question is how much exerciseis needed.In onestudyfromtheWomens
HealthInitiative, as little as 1 to 2 hours perweek ofbrisk walking reduced a womans
risk by18%. Walking10 hoursaweek reduced therisk alittlemore.
To reduceyour risk ofbreast cancer, theAmerican CancerSocietyrecommends that adults
get at least 150 minutes ofmoderateintensityor75 minutes ofvigorous intensity
activityeach week (oracombination ofthese), preferablyspread throughout theweek.
Moderateactivityis anythingthat makesyou breathe as hardasyou do duringabrisk walk.
Duringmoderateactivities,youll noticeaslight increasein heart rate and breathing. You
should beableto talk, but not sing duringtheactivity. Vigorous activities areperformed at
ahigherintensity.Theycause anincreased heart rate, sweating, anda fasterbreathingrate.
Activities that improvestrength and flexibility, such asweight lifting, stretching, oryoga,
arealso beneficial.

Havingchildren
Women who havenot had children orwho had their first child afterage30havea
slightlyhigherbreast cancer risk overall. Having manypregnancies and becoming pregnant
at anearlyagereduces breast cancer riskoverall. Still, the effect ofpregnancyis

differentfordifferent types ofbreast cancer.Foracertain typeofbreast cancerknownas

triple-negative, pregnancyseems to increase risk.

Birth control
Oral contraceptives:Studies have found that women usingoral contraceptives (birth
control pills)haveaslightlyhigher risk ofbreastcancerthan women who havenever used
them. Oncethepillsarestopped, this risk seems to go back to normal overtime. Women
who stopped usingoral contraceptives morethan 10years ago donot appearto have
anyincreased breast cancer risk. When thinkingabout usingoralcontraceptives, women
should discuss theirother risk factors forbreast cancerwith theirhealth care provider.
Birthcontrol shot: Depo-Proverais an injectableform ofprogesteronethats given once
every3 months as birth control. A few studies havelooked at theeffect ofbirth control
shots on breast cancerrisk. Women currentlyusingbirth control shots seem to have an
increasein breastcancerrisk, but it appears that thereis no increasedrisk in women 5 years
aftertheystopgettingtheshots.

Hormone therapyafter menopause

Hormonetherapywith estrogen(oftencombinedwith progesterone)has been used for many
years to help relievesymptoms ofmenopause and help prevent osteoporosis
(thinningofthebones).This treatment goes bymanynames, suchas post-menopausal
hormonetherapy(PHT),hormone replacement therapy(HRT),and menopausal hormone
therapy(MHT).
Thereare2 main types ofhormonetherapy. Forwomen who still haveauterus (womb),
doctors generallyprescribe estrogenand progesterone (knownas combined hormone
therapyorHT). Progesteroneis needed becauseestrogenalonecan increasethe risk of
canceroftheuterus. Forwomen whovehad ahysterectomy(thosewho nolongerhavea
uterus), estrogen alonecan beused. This is known as estrogen replacement therapy
(ERT)orjust estrogen therapy(ET).
Combined hormone therapy (HT):Useofcombined hormonetherapyaftermenopause
increases the risk ofbreast cancer.It mayalso increasethe chances ofdyingfrom breast
cancer. This increasein risk can beseen with as little as 2years ofuse. Combined HT also
increases thelikelihood that the cancermaybe found at amore advanced stage.
(This means its alreadyspread from theplaceit started when its found.)
Theincreased risk from combined HT appears to applyonlyto current and recent users.
A womans breast cancerrisk seems to return to that ofthegeneral population within 5
years ofstoppingtreatment.

Bioidentical hormonetherapy:Theword bioidentical is sometimes used to describe

versions of estrogenandprogesteronewith thesame chemical structure asthose found
naturallyin people. Theuseofthesehormones has been marketed as asafewayto treat
thesymptoms ofmenopause.Its important to realizethat becausetherearent many studies
comparing bioidenticalornaturalhormones to syntheticversions of hormones, theres
no proofthat theyresaferormore effective. Morestudies areneeded to know forsure.
Theuseofthesebioidentical hormones should bethoughtto havethe samehealth risks as
anyothertypeofhormonetherapy.
Estrogentherapy (ET):Theuseof estrogen alone aftermenopausedoes not seem to
increasethe risk ofbreastcancermuch, ifat all. But when used longterm (formorethan
10years), EThas been found to increasethe risk ofovarianand breast cancerin some
studies.
At this timethere arefewstrongreasons to usepost-menopausal hormonetherapy(either
combined HT orET), otherthan possiblyfortheshort-term reliefofmenopausal symptoms.
Alongwith theincreased risk ofbreastcancer, combined HT also appears to increasethe
risk ofheartdisease, blood clots, andstrokes.It does lowertherisk of colorectalcancer and
osteoporosis, but this mustbeweighedagainst thepossibleharms,
especiallysincethereareotherways to prevent and treat osteoporosis and screening can
sometimes prevent coloncancer. ET does not seem to increasebreast cancer risk, but it
does increasethe risk ofstroke.
Thedecision to useHT should bemadebyawoman and herdoctorafterweighingthe
possible risks and benefits (includingtheseverityofhermenopausal symptoms), and
consideringherother risk factors forheart disease, breastcancer, and osteoporosis.If
theydecidesheshould tryHTforsymptoms ofmenopause, its usuallybest to useit at
thelowest dosethat works forherand foras shortatime as possible.

Breastfeeding
Somestudies suggest that breastfeedingmayslightlylowerbreast cancer risk, especially
ifits continued for1 to 2years.But this has been hard to study, especiallyin countries
liketheUnited States, wherebreastfeedingforthis longis uncommon.
The explanation forthis possible effect maybethat breastfeedingreducesawomans
total numberoflifetimemenstrual cycles(thesame as startingmenstrualperiods at alater
ageorgoingthrough earlymenopause).

Factorswithuncleareffectonbreastcancerrisk
Therearesomethings that might be risk factors forbreast cancer, but theresearch is not
yetclearabout whethertherereallyis alink. Theyincludethings liketobacco smoke and
working at night.

Diet andvitamins
Manystudies havebeendonelookingforalink betweencertain diets andbreast cancer risk,
but so fartheresults havebeen conflicting. Results ofsomestudies haveshown that diet
mayplaya role, whileothers showed noevidencethat diet influences breast cancer risk.
Studies lookingat vitamin levels havehad inconsistent results. And somestudies have
found that higherlevels of certain nutrients increased the risk forbreast cancerin women.
So far, no studyhas shown that takingvitamins reduces breast cancer risk.This is not to
saythat theres no point in eating ahealthydiet. Adiet low in fat, low in red meat and
processed meat, and highin fruits and vegetablescan haveotherhealth benefits.
Manystudies ofwomen in theUnited States havenot linked breast cancer risk to fat in
thediet. Still, studies have found that breast canceris less common in countries wherethe
typical diet is low in total fat, low in polyunsaturated fat, and low in saturated fat.
Researchers arestill not surehow to explain this.It maybeat least partlydueto the
effect ofdiet on bodyweight (seebelow).Also, studies comparingdiet andbreast cancer
risk in different countriesare complicated byotherdifferences (such as activitylevel,
intakeofothernutrients,and geneticfactors)thatmight also affect breast cancerrisk.
More research is neededto betterunderstand the effect ofthetypes offat eaten on breast
cancer risk.Itsclearthat calories do count,and fat is amajorsourceofcalories. High-fat diets
can lead to beingoverweight orobese, whichis aknown breastcancerrisk factor. A diet high
in fat is also arisk factor forsomeothertypes of cancer.And intakeof certain types offat is
clearlyrelated to higherrisk ofheartdisease.

Chemicals in the environment

A great deal ofresearchhas been reportedand moreis beingdoneto understand possible
environmental influenceson breast cancer risk.
Compounds in the environment that have estrogen-likepropertiesareofspecial interest.
For example, substancesfound in someplastics, certain cosmetics and personal care
products, pesticides, andPCBs (polychlorinated biphenyls)seem to havesuch properties.
In theory, thesecould affect breast cancerrisk.
This issue raises agreatdeal ofpublic concern, but at this time research does not show a
clearlink between breastcancer risk andexposureto thesesubstances. Studyingsuch
effects in humans is hardto do. More research is needed to betterdefinethepossible health
effects ofthesesubstances and others likethem.

Tobacco smoke
Foralongtime, studies showed no link betweencigarettesmoking and breast cancer.But in
recentyears, morestudies haveshown that heavysmokingoveralong-timeis linked
to ahigher risk ofbreastcancer.In somestudies, the risk was highest in certain groups,
such as women who started smokingbeforetheyhad their first child. The2014 US
SurgeonGenerals reporton smokingconcluded that thereis suggestivebut not
sufficient evidencethat smokingincreases the risk ofbreast cancer.
Researchers arealso lookingat whethersecondhand smokeincreases the risk ofbreast
cancer.Both mainstreamand secondhand smokecontain chemicals that, inhigh
concentrations, causebreast cancerin rodents. Studies haveshown that chemicals in
tobacco smokereach breast tissue and arefound in breast milk of rodents.
In humanstudies, the evidenceon secondhand smoke and breast cancerrisk is not clear, at
least in part becausethelink between smokingand breast canceris also not clear. One
reason forthis might bethat tobacco smokemayhavedifferent effects on breast cancer risk
in smokers compared with thosewho arejustexposed to secondhand smoke.
A report from theCaliforniaEnvironmental Protection Agencyin 2005 concluded that the
evidence about secondhand smoke and breastcanceris consistent with a causal
associationinyounger,mainlypre-menopausal women. The2014 US Surgeon Generals
report concluded that thereis suggestivebut not sufficient evidenceofalink at this
point.In anycase,this possiblelink to breast cancerisyet anotherreason to avoid
secondhand smoke.

Nightwork
Somestudies havesuggested that women who work at night, suchas nurses on anight
shift, might have an increased risk ofbreast cancer. This is a fairlyrecent finding, and
morestudies arelooking at this. Some researchersthink the effect maybedueto changes in
levels ofmelatonin, ahormonethats affected bythebodysexposureto light, but
otherhormones are alsobeingstudied.

Disprovenorcontroversialbreastcancerriskfactors
Therearemanyfactors that research has shown arenot linked to breast cancer. You may
seeinformation onlineorhear about thesedisproven or controversial risk factors, but it is
important to learn the facts.

Antiperspirants
Internet ande-mail rumors havesuggested that chemicals in underarm antiperspirants are
absorbed through theskin, interferewith lymph circulation, and causetoxins to build up in
thebreast, eventuallyleadingto breastcancer.
Based on the available evidence (includingwhat weknow about how thebodyworks),
thereis littleif anyreason to believethat antiperspirants increasethe risk ofbreast cancer.
Formoreinformation, read Antiperspirants and Breast Cancer Risk.

Bras
Internet ande-mail rumors and at least onebook havesuggested that bras causebreast
cancerbyobstructinglymph flow. Thereis nogood scientificor clinical basis forthis
claim, and arecent studyofmorethan 1,500 women found no association between
wearingabraand breast cancer risk.

Inducedabortion
Several studies haveprovided verystrongdatathat neitherinducedabortions nor
spontaneous abortions (miscarriages)havean overall effect on therisk ofbreast cancer.
Formoredetailed information, read Is Abortion Linked to Breast Cancer?

Breast implants
Several studies havefound that breast implants do not increasethe risk ofbreast cancer,
although siliconebreast implants can causescartissueto form in thebreast.Implants
makebreast tissueharderto seeon standard mammograms, but additionalx-raypictures
called implant displacement views can beused toexaminethebreast tissuemore
completely.
Breast implants might belinked to a raretypeoflymphomacalled anaplasticlargecell
lymphoma. This lymphomahas rarelybeenfoundin thebreast tissue around the implants.
So far, though,therearetoo few cases to know ifthe risk ofthis lymphomais
reallyhigherin womenwith implants.

Doweknow what causesbreast cancer?

Manyrisk factors can increaseyour chanceofdevelopingbreast cancer, but it is notyet
known exactlyhow someofthese risk factors cause cells to becomecancerous.
Hormones seem to playarolein manycases ofbreast cancer, but just howthis happens is not
fullyunderstood.

Normal breast cells become cancerous becauseofchanges (mutations)in DNA. Some

DNA mutations areinherited. This means themutations arein everycell inyourbody and
can dramaticallyincreasetherisk fordevelopingcertain cancers. Theyare responsible
formanyofthe cancers that run in some families.
But most DNA changes related to breast cancerare acquired in breast cellsduringa
woman's life ratherthanhavingbeen inherited.
DNA is the chemical in each ofourcells that makes up ourgenes.Genes have instructions
forhow ourcells function. Weusuallylook likeourparents becausetheyare
thesourceofourDNA.But DNAaffects morethan how welook. Somegenes control when
ourcells grow, divideinto new cells, and die.

Oncogenes
Genes that speed up celldivision are called oncogenes. Proto-oncogenes aregenes that
normallyhelpcellsgrow.When aproto-oncogenemutates (changes)orthere aretoo
manycopies ofit, it becomes a"bad" genethatcan becomepermanentlyturned on or
activated when it is not supposed to be. When this happens, thecell growsout of control,
which can lead to cancer.This bad geneis calledan oncogene.
Think ofa cell asa car. Forthe carto work properly, thereneed to bewaysto control how
fast it goes. A proto-oncogenenormallyfunctions in awaythat is much likeagas pedal.It
helps thecell grow and divide. An oncogene could becompared with agas pedal that is
stuck down, which causes thecell to divideout of control.

Tumorsuppressiongenes
Tumorsuppressorgenesarenormal genes that slow down cell division, repairDNA
mistakes, ortell cells when to die (aprocess known as apoptosis orprogrammed cell
death). When tumorsuppressorgenes don't work properly, cells cangrow out of control,
which can lead to cancer.
A tumorsuppressorgeneis likethebrakepedal on a car.It normallykeepsthe cell from
dividingtoo quickly, justas abrakekeeps acarfrom goingtoo fast. Whensomething
goeswrongwith thegene, such as amutation, cell division can get out ofcontrol.
Certain changes (mutations)in DNA that turn ononcogenes or turn offtumor
suppressorgenes cancausenormal breast cells to becomecancerous.

Inheritedgenechanges
Certain inherited DNA mutations (changes)can dramaticallyincreasetherisk for
developing certain cancers and are responsibleformanyofthe cancers that run in some
families. For example, theBRCA genes (BRCA1 and BRCA2) aretumorsuppressor

genes. A changein oneofthesegenes can beinherited from aparent. When oneofthese

genes changes, it no longersuppresses abnormalgrowth, and canceris morelikelyto
develop.
Women have alreadybegun to benefit from advances in understandingthegeneticbasis
ofbreast cancer. Genetictestingcan identifysomewomen who haveinherited mutations in
theBRCA1 orBRCA2 tumorsuppressorgenes(orless commonlyin othergenes such as
PTENorTP53). Thesewomen can then takesteps to reducetheir risk ofdeveloping breast
cancers and to monitor changes in theirbreasts carefullyto findcancer atan earlier,
moretreatablestage.(SeeForwomen who areormaybe at increased riskin Can breast
cancerbeprevented?)
Mutations in tumorsuppressorgenes liketheBRCA genes are considered highpenetrancebecausetheyoften lead to cancer. Although manywomen with highpenetrancemutations develop cancer, most cases of cancer (includingbreastcancer)are
not caused bythis kind ofmutation.
Moreoften, low-penetrancemutations orgenevariations areafactorin cancer
development. Each ofthesemayhaveasmall individual effect on cancerdevelopment, but
theoverall effect on thepopulation can belargebecausetheyarecommon, and peopleoften
areaffectedwith morethan one at thesametime. Thegenes involved may affect things
likehormonelevels, metabolism orotherthings that interact with risk factors forbreast
cancer.Thesegenes mayberesponsible formuch ofthe risk ofbreast cancerthat runs in
families.

Acquiredgenechanges
Most DNA mutations related to breastcanceroccurin breast cells during awoman's life
ratherthan havingbeen inherited. Theseacquiredmutations ofoncogenes and/ortumor
suppressorgenes mayresult from other factors, like radiation orcancer-causing
chemicals.But so far, thecauses ofmost acquiredmutations that could lead to breast
cancerarestill unknown. Most breast cancers haveseveral acquiredgenemutations.
Tests to spot acquiredgene changes mayhelp doctors more accuratelypredict theoutlook
(prognosis) forsomewomen with breast cancer.For example, tests can identifywomen
whosebreast cancercells havetoo manycopies oftheHER2 oncogene. These cancers tend to
bemoreaggressive. At thesametime, drugs havebeendeveloped that specifically target
thesecancers and improveoutcomes forpatients.
SeeGenes and Cancer formoreinformation abouthow genes can affectcancer risk and
treatment.

Can breast cancer be prevented?

Thereis no surewayto prevent breast cancer. Buttherearethingsyoucando that might
loweryour risk, suchas changingriskfactors thatyou can control.

Healthhabits
Bodyweight, physicalactivity,and diet haveall been linked to breast cancer, so these
might be areas whereyou can takeaction. Read theAmerican Cancer SocietyGuidelines
on Nutrition and Physical Activityfor Cancer Prevention to learn more.

Medicaloptionsforwomenatincreasedrisk
Forwomenwho havecertain risk factors forbreast cancer, such asa familyhistory, there
areanumberofmedicaloptions that mayhelp prevent breast cancer.

Drugstoreduce risk
Forwomenat increased risk ofbreast cancer, drugs such as tamoxifen and raloxifene
havebeen shown to reducethe risk, but thesedrugs can havetheirown risks and side
effects. Otherdrugs, such as aromataseinhibitors, and dietarysupplementsthat mayhelp
lower risk are also being studied. SeeMedicines toReduceBreast Cancer Riskformore
information.

Preventive surgery
Ifyou haveastrongfamilyhistoryofbreast cancer,youcan talk toyourdoctor about
genetictesting formutations in genes that increasethe risk ofbreast cancer,such as the
BRCA genes.Ifyou haveageneticmutation or come from afamilywith amutation but
havent been tested,youcould considersurgerytoloweryour risk ofcancer.

Can breast cancer befound early?

Tests and exams used to find adisease, likecancer, in peoplewho do not have any
symptoms arecalled screeningtests. Screeningexams, such as mammograms, find
cancers beforetheystartto causesymptoms. This is called earlydetection.Cancers that are
foundearlywhen theyresmall and havent spread areeasierto treat and have
betteroutcomes
Breast Cancer Prevention and EarlyDetection has moredetails about theAmerican
CancerSociety guidelines forthe earlydetection ofbreast cancer.

Whyisitimportanttofindbreastcancerearly?
The earlierbreast canceris found, thebetterthe chances that treatment will work. Breast
cancers that are found becausetheycan befelt tend to belargerand aremorelikelyto have
alreadyspread outsidethebreast. But screeningexams can often findbreast cancers when
theyaresmall andstill confined to thebreast. Thesizeofabreast cancer and how farit has
spread aresomeofthemost important factors in predictingtheoutlook
(prognosis)ofawomanwith this disease.
Most doctors feel that earlydetection tests forbreast cancersavethousandsoflives each
year. Manymorelives probablycould besaved ifeven morewomen and theirhealth care
providers took advantageofthesetests.

Signs and symptoms of breast cancer

Knowinghowyourbreasts normallylook and feelis an important part ofkeepingup with
yourbreast health. Findingbreast cancer as earlyas possiblegivesyouabetter chanceof
successful treatment. Butknowingwhat to look fordoes not taketheplaceofhaving
regularmammograms and otherscreeningtests. Screeningtests can help find breast
cancerin its earlystages, even beforeanysymptoms appear.
Themost common symptom ofbreast canceris anew lump ormass. A painless, hard mass
that has irregular edges is morelikelyto be cancerous, but breast cancers can be tender,
soft, orrounded.Theycaneven bepainful. Forthis reason, it is important to have anynew
breast mass orlump orbreast change checked byahealth careprofessional experienced in
diagnosingbreast diseases.
Otherpossiblesymptomsofbreast cancerinclude:
Swellingof all orpart ofabreast (even ifno distinct lump is felt)
Skin irritation ordimpling
Breast ornipplepain
Nipple retraction (turninginward)
Redness, scaliness, orthickeningofthenippleorbreast skin
Nippledischarge(otherthan breast milk)
Sometimes abreast cancer can spread to lymph nodes underthearm oraround the collar
bone and causealump orswellingthere, even beforetheoriginal tumorinthebreast tissueis
largeenough tobe felt. Swollen lymph nodes should also be reported toyour doctor.

Although anyofthesesymptoms can be caused bythings otherthan breastcancer, ifyou

havethem, theyshould be reported toyourdoctorso that heorshecan findthe cause.
Becausemammograms do not find everybreast cancer, it is important foryou to be
awareof changes inyourbreasts and to know thesigns and symptoms ofbreast cancer.

Howis breast cancer diagnosed?

Breast canceris sometimes found aftersymptoms appear, but manywomenwith early
breast cancerhaveno symptoms. This is whygettingtherecommended screeningtests (as
described in "Can breast cancerbefound early?")before anysymptomsdevelop is so
important.
Ifsomethingsuspicious is found during ascreeningexam, orifyou have anyofthe
symptoms ofbreast cancerdescribed in theprevious section,yourdoctorwill useoneor
moremethods to find out ifthediseaseis present.Ifcanceris found,othertests will be doneto
determinethestage(extent)ofthecancer.

Medicalhistoryandphysicalexam
Ifyou thinkyou have anysigns orsymptoms that might mean breast cancer, besureto
seeyourdoctor as soon as possible. Yourdoctorwill askyou questions aboutyour
symptoms, anyotherhealth problems, and possible risk factors forbenignbreast
conditions orbreast cancer.
Yourbreasts will bethoroughlyexamined foranylumps orsuspicious areas and tofeel
theirtexture, size, and relationship to theskin and chest muscles. Anychanges in the
nipples ortheskin ofyourbreasts will benoted. Thelymph nodes inyourarmpit and
aboveyour collarbonesmaybepalpated(felt), becauseenlargement or firmness ofthese
lymph nodes might indicatespread ofbreast cancer. Yourdoctorwill also do a complete
physicalexam to judgeyourgeneral health and whetherthereis anyevidenceofcancer that
mayhavespread.
Ifbreast symptoms and/orthe results ofyourphysical exam suggest breastcancermight
bepresent, moretests will probablybedone. Thesemight includeimaging tests, looking at
samples ofnippledischarge, ordoingbiopsiesofsuspicious areas.

Imagingtestsusedtoevaluatebreastdisease
An imagingtest is awayto seewhatsgoingon insideyourbody.Thepictures can show
normal bodystructures and functions, as well as abnormal ones caused bydiseases like
cancer.

These aresomeofthemore common imagingtests used to look fororlearn more about

breast changes and breastcancer:

Mammograms
A mammogram is an x-rayofthebreast. Screeningmammogramsareusedto look for breast
changes in womenwho haveno signs orsymptoms ofabreast problem. Screening
mammograms usuallytake2 views (x-raypictures taken from differentangles)of each
breast. Diagnosticmammogramsareused to geta closerlook ofa changeseen on a
screeningmammogram. Morepicturesaretaken ofthe areathat maybecancer.
SeeMammograms and Other BreastImaging Tests formoredetailed information.

Breast ultrasound
Ultrasound, also known as sonography, uses sound waves to outlineapart ofthebody.
Its useful forlookingatsomebreast changes, such as thosethat can be feltbut not seen on
amammogram.It also helps tell thedifferencebetween fluid-filled cysts and solid masses.
SeeMammograms and Other Breast Imaging Tests formoredetailed information.

Magneticresonanceimaging(MRI)of the breast

MRIs useradio waves and strongmagnets insteadofx-rays. The energyfrom the radio
waves is absorbed and then released in apattern formed bythetypeofbodytissue and by
certain diseases. A computertranslates thepatterninto averydetailed picture. Forbreast
MRIto look forcancer, acontrast liquid called gadolinium is injected intoavein before
orduringthescan to show details better.
SeeMammograms and Other Breast Imaging Tests formoredetailed information.

Ductogram(galactogram)
A ductogram, also calledagalactogram, is sometimes used to help find thecauseofany
worrisomenippledischarge.In this test, averythin metal tubeis put into theopeningofa duct
in thenipplethat thedischargeis comingfrom. A small amount of contrast material is put
in.It outlines theshapeoftheduct on x-rayand can show iftheres is amass inside theduct.If
fluid is comingfromyournipple, someofthe fluid maybe collected and checked forsigns
ofinfection or cancercells.

Biopsyprocedures
A biopsyis donewhen mammograms, otherimagingtests, orthephysical exam shows a
breast changethat maybe cancer. A biopsyis theonlywayto knowforsureifits cancer.
Forabiopsy, asample (tinypiece)ofthesuspicious areais taken out and tested in thelab.
Thesampleiscalled abiopsyspecimen. SeeForWomen Facinga Breast
Biopsyformoreinformation.

Howis breast cancer classified?

Afteryou haveabiopsy,thesamples ofbreast tissue arelooked at in thelab to determine
whetherbreast canceris present and ifso, whattypeit is. Certain lab tests maybedone that
can help determinehow quicklya canceris likelytogrow and (to some extent)what
treatments arelikelyto be effective. Sometimes thesetests arent doneuntil the entire
tumoris removed byeitherbreast-conservingsurgeryormastectomy.
Ifabenigncondition is diagnosed,you will needno furthertreatment. Still, it is important
to find out fromyourdoctorifthebenign condition putsyou athigherrisk for breast
cancerin the future and what typeoffollow-upyou might need.
Ifthediagnosis is cancer,thereshould betime foryou to learn about thedisease and to
discuss treatment options withyourcancercareteam, friends, andfamily.It is usuallynot
necessaryto rush into treatment. You might wantto get asecond opinion beforedeciding
what treatment is best foryou.

Breastcancertype
Thetissue removed duringthebiopsy(orduringsurgery)is first lookedat undera
microscopeto seeif canceris presentand whetherit is a carcinomaorsomeothertypeof
cancer (likeasarcoma).Ifthereis enough tissue, thepathologist maybeableto
determineifthecancerisin situ (not invasive)orinvasive. Thebiopsyis also used to
determinethecancer's type, such as invasiveductal carcinomaorinvasivelobular
carcinoma. See"What is breast cancer?"formoreabout each type.
With an FNA (fineneedle aspiration)biopsy, notas manycells areremoved and they
often becomeseparated from the rest ofthebreasttissue, so it is often onlypossibleto
saythatcancercells arepresent without beingableto sayifthecanceris in situ or invasive.
Themost common typesofbreast cancer, invasiveductal and invasivelobular cancer,
generallyaretreated in thesameway.

Breastcancergrade
A pathologist also assigns agradeto thecancer, which is based on how closelythe
biopsysamplelooks likenormal breast tissue andhow rapidlythe cancercells are dividing.
Thegradecanhelp predict awoman's prognosis.Ingeneral, alowergrade numberindicates
aslower-growingcancerthat is less likelyto spread, whileahigher numberindicates
afaster-growingcancerthat is morelikelyto spread. Thetumorgrade is one factorin
decidingif furthertreatment is needed aftersurgery.
Forinvasivecancers, thehistologictumorgradeissometimes called theBloomRichardson grade, Nottingham grade, Scarff-Bloom-Richardson grade, orElston-Ellis
grade. Sometimes thegradeis expressed with words instead ofnumbers:
Grade1 is thesame as well differentiated
Grade2 is thesame as moderatelydifferentiated.
Grade3 is thesame as poorlydifferentiated
Grade3cancers tend togrow and spread morequickly.
Understanding Your PathologyReport:Breast Cancer has moreinformation about
gradinginvasivecancers.
DCISis alsograded, butthegradeis based onlyon how abnormal thecancer cells appear
(nucleargrade). Thepresenceofnecrosis (areas ofdead ordyingcancercells)is also noted.
Theterm comedocarcinoma is often used todescribeDCISwith prominent
necrosis.Ifabreast ductis filled with aplugofdead and dyingcells, theterm comedonecrosis
maybeused. Theterms comedocarcinoma and comedonecrosis are linked to
ahighergradeofDCIS.
Understanding Your PathologyReport:Ductal CarcinomaIn Situ has moreon grading
DCIS.

Teststoclassifybreastcancers
Estrogen receptors(ER) and progesterone receptors(PR)
Receptors areproteins inoron certain cells that can attach to certain substances, such as
hormones, that circulatein theblood. Normal breast cells and somebreast cancercells
contain receptors that attach to estrogenand progesterone. These2 hormones often fuel
thegrowth ofbreast cancer cells.
An important step in evaluatingabreastcanceris to test the cancerremovedduringthe
biopsy(orsurgery)to seeifit has estrogen and progesteronereceptors. Cancercells may
haveneither, one, orbothofthese receptors.Breast cancers that haveestrogen receptors

areoften referred to as ER-positive(orER+) cancers, whilethose containing

progesteronereceptors are called PR-positive(orPR+) cancers.
All invasivebreast cancers should betested forboth ofthesehormonereceptors eitheron
thebiopsysampleorwhen theyareremoved withsurgery. About 2 of3 breast cancers have at
least oneofthesereceptors. This percentageis higherin olderwomen than in
youngerwomen. DCISshould be checked forestrogenreceptors, as well.

HER2/neu testing
About 1 of5 breastcancers havetoo much ofagrowth-promotingproteincalled HER2/neu
(often just shortened to HER2). TheHER2/neu geneinstructs the cells to makethis
protein. Tumors with increased levels ofHER2/neu arereferred to as HER2- positive.
Cancers that areHER2-positivehavetoo manycopies oftheHER2/neugene, resultingin
greaterthan normal amounts oftheHER2/neu protein. Thesecancers tendto growand
spread more aggressivelythan otherbreast cancers.
All newlydiagnosed invasivebreast cancers should betested forHER2/neu because
HER2-positive cancers aremuch morelikelyto benefit from treatment with drugs that

target theHER2/neu protein, such as trastuzumab(Herceptin ) and lapatinib (Tykerb ).

DCISis not tested forHER2 becauseit is not treated with thesedrugs.
A biopsyorsurgerysampleis usuallytested in 1of2 ways:
Immunohistochemistry(IHC):In this test, special antibodies that identifythe
HER2/neu protein are applied to thesample, which causecells to change colorif
manycopies arepresent.This color changecan beseen underamicroscope. Thetest
results arereportedas 0,1+, 2+, or3+.
Fluorescent in situ hybridization (FISH): This test uses fluorescent piecesofDNA
that specificallystick to copies oftheHER2/neugenein cells, whichcan then be
counted underaspecial microscope.
Manybreast cancerspecialists feel theFISH test is more accuratethanIHC. However, it is
more expensive and takes longertoget theresults. Often theIHCtest is used first.If the
results are1+ (or0), the canceris consideredHER2-negative. Peoplewith HER2negativetumors arenot treated with drugs(liketrastuzumab)that target HER2.Ifthetest
comes back 3+, thecanceris HER2-positive. Patients with HER2-positivetumors maybe
treated with drugs liketrastuzumab. When the result is 2+, theHER2 status ofthetumor
is not clear. This usuallyleads to testingthetumorwith FISH. Someinstitutions also use
FISH to confirm HER2 status that is 3+byIHCand someperform onlyFISH.
A newertypeoftest, known as chromogenicin situ hybridization (CISH),works
similarlyto FISH, byusingsmall DNA probes tocount thenumberofHER2 genes in

breast cancer cells.But this test looks for color changes (not fluorescence)and doesn't
requireaspecial microscope, which could makeit less expensive. Right now, it is not
beingused as much asIHCorFISH.

Classifyingbreast cancer based on hormone receptorsandHER2 status

Doctors often divideinvasivebreast cancers into groups based on thepresenceof
hormone receptors (ER and PR) and whetherornot the cancerhas too much HER2.
Hormone receptor-positive:Ifthebreast cancercells contain eitherestrogen or
progesteronereceptors, theycan be called hormone receptor-positive (orjust hormonepositive). Breast cancersthat arehormone receptor-positive can betreatedwith hormone
therapydrugs that lowerestrogen levels orblock estrogenreceptors. This includes cancers
that areER-negativebut PR-positive. Hormone receptor-positivecancers tend to grow
moreslowlythan thosethat arehormonereceptor-negative(and dont have either estrogen
orprogesteronereceptors). Women with these cancers tend to haveabetter outlook in
theshort-term, but cancers that arehormone receptor-positivecan sometimes comeback
many years aftertreatment. Hormonereceptor-positive cancersaremore common in
women aftermenopause.
Hormone receptor-negative:Ifthebreast cancercells dont haveeither estrogen or
progesteronereceptors, theyaresaid to behormone receptor-negative (orjust hormonenegative). Treatment with hormonetherapydrugsis not helpful forthesecancers. These
cancers tend togrow morequicklythan hormonereceptor-positive cancers.Iftheyreturn
aftertreatment, it is moreoften in the first fewyears. Hormonereceptor-negativecancers
aremore common in women who havenotyetgonethrough menopause.
HER2 positive: Cancers that havetoo much HER2 protein or extra copiesoftheHER2
gene arecalled HER2 positive. These cancerscanbetreatedwith drugs that target HER2.
HER2 negative: Cancersthat dont have excess HER2 arecalled HER2 negative. These
cancers do not respond totreatment with drugs that target HER2.
Triple-negative:Ifthebreast cancer cells dont have estrogen orprogesterone receptors
and dont havetoo muchHER2, theyarecalled triple-negative. Thesecancers tend to
occurmoreoften inyoungerwomen and in women who areAfrican-American or
Hispanic/Latina. Triple-negativebreast cancers tend to growand spread morequickly
than most othertypes ofbreast cancer. Becausethetumor cells dont havehormone
receptors, hormonetherapyis not helpful in treatingthesecancers.Becausetheydont
havetoo much HER2, drugs that target HER2 arent helpful, either. Chemotherapycan
still beuseful, though.
Triple-positive: This term is used to describecancers that areER-positive,PR-positive,
and havetoo much HER2. Thesecancers can betreated with hormonedrugs as well as
drugs that target HER2.

Othertestsofbreastcancers
Tests of ploidyand cellproliferation rate
Theploidyofcancercells refers to the amount ofDNA theycontain.Ifthere's anormal
amount ofDNA in thecells, theyaresaid to bediploid.Iftheamount is abnormal, then the
cells aredescribed asaneuploid. Tests ofploidymayhelp determineprognosis, but
theyrarelychangetreatment and are considered optional. Theyarenot usually
recommendedas part ofa routinebreast cancer work-up.
TheS-phasefraction is thepercentageofcells in asamplethat are replicating(copying)
theirDNA. DNA replication means that the cell is gettingreadyto divideinto 2 new
cells. The rateofcancercell division can also beestimated byaKi-67 test.IftheS-phase
fraction orKi-67 labelingindexis high, it meansthat the cancercells aredividingmore
rapidly,which indicatesamoreaggressivecancer.

Tests ofgene patterns

Researchers have found that lookingat thepatterns ofanumberofdifferent genes at the
sametime (sometimes referred to as gene expression profiling) can help predict whether
ornot an early-stagebreast canceris likelyto comebackafterinitial treatment. Two such

tests, which look at different sets ofgenes,arenow available: theOncotypeDX and the

MammaPrint

OncotypeDX :TheOncotypeDX testcan behelpful when decidingwhether additional

(adjuvant)treatment with chemotherapy(aftersurgery)might beuseful inwomen with
early-stagebreast cancers that arehormonereceptor-positive. This test is most often used
fortumors that aresmall (1 cm orless)and havenot spread to lymph nodes, but it can be
used formoreadvanced tumors.
Thetest looks at aset of21 genes in cells from tumorsamples to determinea recurrence
score,which is anumberbetween 0and 100:
Cancers with arecurrencescoreof17 orbelow havealow risk ofrecurrence (cancer
comingback aftertreatment)iftheyaretreated with hormonetherapy. Women with
these cancers would probablynot benefit from chemotherapy.
Cancers with ascoreof18 to 30 are at intermediate risk of recurrence. Somewomen
with these cancers might benefit from chemotherapy.
Cancers with ascoreof31 ormore are at high riskof recurrence. Women with these
cancers arelikelyto benefit from chemotherapyinaddition to hormonetherapy.
Thetest estimates risk and helps predict who would belikelyto benefit from
chemotherapy. Still, it cannot tell for certain ifanyparticularwoman will havea
recurrencewith orwithout chemotherapy.It is atool that can beused,alongwith other

factors, to helpguidewomen and theirdoctors when decidingwhethermoretreatment

might beuseful.

MammaPrint :This test can beused to help determinehow likelybreast cancersareto

recurinadistant part ofthebodyafterinitial treatment.
Thetest looks at the activityof70 differentgenesto determineifthecanceris low risk or high
risk. So farthough,it hasnt been studied to seeiftheresults areuseful in guiding treatment.
Usefulness ofthese tests:Manydoctors usethesetests (along with otherinformation)to
help makedecisions about offeringchemotherapy, but theyarent needed in all cases.
Thesetests arenow beinglookedat furtherin largeclinical trials.In themeantime, women
might want to ask theirdoctors ifthesetests might beuseful forthem.

Classifyingbreastcancerbasedongeneexpression
Research on patterns ofgene expression has also suggested somenewerwaysto classify
breast cancers. The current types ofbreast cancerarebased largelyon howtumors look
underamicroscope. A newerclassification, based on molecularfeatures,divides breast
cancers into 4 groups. This testing, called thePAM50, is currentlyavailablebut it isnt
clearthat it is anymorehelpful in guidingtreatment than tests ofhormonereceptors and
HER2:
Luminal A andluminalBtypes:Theluminal types areestrogen receptor(ER)positive.
Thegeneexpression patterns ofthesecancersaresimilarto normal cells that linethe breast
ducts andglands(theinsideofaduct orgland is called its lumen).Luminal A cancers
arelowgrade, tend to growfairlyslowly,and havethebest prognosis.Luminal B
cancersgenerally grow somewhat fasterthan luminal A cancersand theiroutlook is not
as good.
HER2 type:Thesecancers haveextra copies oftheHER2gene and sometimes some others.
Theyusuallyhaveahigh-grade appearanceunderthemicroscope.Thesecancers tend to grow
morequicklyand haveaworseprognosis, although theyoften can betreated successfullywith
targeted therapies aimedat HER2 which areoftengivenalongwith chemotherapy.
Basal type:Most ofthese cancersareoftheso-called triple-negativetype,that is, they lack
estrogen orprogesterone receptorsand havenormal amounts ofHER2. Thegene
expression patterns ofthese cancers aresimilarto cells in thedeeperbasallayers of breast
ducts andglands.This typeis morecommon amongwomen with BRCA1 gene mutations.
For reasons that arenot well understood, this canceris also more common
amongyounger andAfrican-Americanwomen.
These arehigh-gradecancers that tend togrow quicklyand haveapooroutlook.
Hormonetherapyand anti-HER2 therapies liketrastuzumab and lapatinib arenot

effectiveagainst these cancers, although chemotherapycan behelpful. Agreat deal of

research is beingdonetofind betterways to treat these cancers.
It is hoped that thesenewbreast cancer classifications might somedayallow doctors to
bettertailorbreast cancertreatments, but moreresearch is needed in this areabeforethis
will bepossible.

Moreontestingbiopsytissuetoclassifycancer
Formoreinformation onhow biopsytissueis looked at and tested bypathologists, see
Testing Biopsyand CytologySpecimens for Cancer.

Tests for breast cancer spread

Ifyou havebeen diagnosed with breast cancer,you might need moretests ifyourdoctor
thinks the cancermayhavespread based onyoursymptoms, the results ofyourphysical
exam, orthesizeofyourtumor.
Chestx-ray:This test maybedoneto seeifthecancerhas spread toyourlungs.
Bonescan:This test can help show ifthe cancerhas spread toyourbones.It can show all
ofthebones ofyourbodyat thesametime and can find small areas ofcancerspread not seen
on plain x-rays.
CTscan(computedtomography):ACT scan is aspecial typeofx-ray.Pictures are taken
from differentangles and are combined byacomputerto makedetailed pictures of
theorgans. This test is most often used to look at the chest and/orbelly(abdomen)to see
ifbreast cancerhas spread to otherorgans.It can also beused to guideabiopsyneedle into
an areaof concern.
MRI (magnetic resonanceimaging):An MRIscan takes pictures usingradio waves and
strongmagnets instead ofx-rays. This test can behelpful in lookingatyourbrainand spinal
cord. MRIscan bemoreuncomfortablethan CT scans becausetheytakelonger
andyou need to liein anarrow tubewhilethetestis done.
Ultrasound:Forthis test, awand thatgives offsound waves is moved overtheskin to
takepictures oftheinsideofthebody. Agel is often put onyourskin first.
PETscan(positron emissiontomography):This test uses a form ofradioactivesugar.
Thesugaris put into avein and travels throughoutthebody. Cancercells absorb high
amounts ofthis sugar.Aspecial camerathen takespictures that show theareas wherethe
sugar collected throughout thebody.

Howis breast cancer staged?

Afterawoman is diagnosed with breast cancer, doctors will figureout whetherit has
spread, and ifso, how far. This is called staging. Thestageofa cancerhelps determine
how serious thecanceris and how best to treat it.

Whatisstaging?
Stagingis theprocess offindingout how widespread thecanceris when itis found. The
stageis themost important factorin decidinghowto treat the cancerand determining how
successful treatmentmight be.
To determinethecancers stageafterabreast cancerdiagnosis, doctors must answer
thesequestions:
Is thecancerinvasiveornon-invasive?
How bigis thebreast tumor?Has it grown into nearbyareas?
Has the cancerspread to nearbylymph nodes?Ifso, how manyareinvolved?
Has the cancerspread to otherparts ofthebody?
Dependingon theresults ofyourphysical exam and biopsy,you might needmoretests to
help determinethestage,such as a chest x-ray, mammograms ofboth breasts, bonescans,
CT scans, MRI,and/orPET scans.Blood tests mayalso bedoneto evaluateyouroverall
health orto check forspread to certain organs.
Afterlookingatyourtestresults,yourdoctorwill tellyou thestageofyourcancer. The earliest
stagecancers arecalled stage0(carcinomain situ), and then rangefrom stagesI
(1)throughIV(4). Someofthestages are furtherdivided into sub stages usingtheletters A, B,
and C.
As a rule, thelowerthenumber, theless thecancerhas spread. A highernumber, such as
stageIV (4), meansamore advancedcancer. Andwithin astage,an earlierlettermeans a
lower (and often better)stage. Cancers with similarstages tend to haveasimilaroutlook and
areoften treated inmuch thesameway.

Understandingyourbreastcancerstage
Breast canceris staged usingtheAmerican Joint Committeeon Cancer (AJCC)TNM
system, which is based on:
Thesizeofthebreast tumor (T) and ifit hasgrown into nearbyareas
Whetherthe cancerhas reached nearbylymph nodes (N)

Whetherthe cancerhasmetastasized (spread to otherparts ofthebody) (M)

OncetheT, N, and M categories foryourcancerhavebeen determined,yourdoctorwill
combinetheinformationto find thestageofthecancer. This process is called stage grouping.
Cancers with similarstages tend to haveasimilaroutlook and areoften treated in
asimilarway.

Stage0

Tis, N0, M0

This is ductal carcinoma in situ (DCIS),apre-cancerofthe

breast. ManyconsiderDCIStheearliest form ofbreast
cancer.In DCIS, cancercells arestill within aduct and have
not invaded deeperinto thesurroundingfattybreast tissue.
Lobular carcinoma in situ (LCIS)sometimes alsois
classified as stage0 breast cancer, but most oncologists
believeit is not atrue cancerorpre-cancer.
Paget diseaseofthenipple (without an underlying tumor
mass)is also stage0.
Inall cases thecancerhas not spread to lymph nodes or
distant sites.

Stage

T1, N0, M0

Thetumoris 2 cm (about3/4 of an inch)orlessacross (T1) and

has not spread to lymph nodes (N0)ordistant sites (M0).

IA

Stage

T0 orT1,

Thetumoris 2 cm orlessacross (oris not found)(T0 orT1) with

IB

N1mi, M0

micrometastases in1 to 3 axillarylymph nodes (the cancerin

theunderarm lymph nodes is greaterthan 0.2mm across
and/ormorethan200 cells but is not largerthan 2 mm)(N1mi).
Thecancerhas not spread to distantsites (M0).

Stage

T0 orT1, N1

Thetumoris 2 cm orlessacross (oris not found)(T1 orT0)

IIA

(butnot

and either:

N1mi), M0:

It has spread to 1 to 3 axillary(underarm)lymph nodes,

with the cancerin thelymph nodes largerthan 2mm
across (N1a),
OR
Tinyamounts ofcancerare found in internal mammary
lymph nodes (nodes nearthebreast bone)on sentinel
lymph nodebiopsy(N1b),
OR
It has spread to 1 to 3 axillarylymph nodesand to
internal mammarylymphnodes (found on sentinel
lymph nodebiopsy)(N1c).
The cancerhas not spread to distant sites (M0).
OR

T2, N0, M0

Thetumoris largerthan2 cm but less than 5 cm (about 2

inches)across (T2)but hasn't spread to thelymphnodes
(N0). Thecancerhas not spread to distant sites (M0).

Stage
IIB

T2, N1, M0

Thetumoris largerthan2 cm but less than 5 cm across (T2). It

has spread to 1 to 3 axillarylymph nodesand/ortiny amounts
of cancerare found in internal mammarylymph nodes on
sentinel lymphnodebiopsy(N1). Thecancerhasn't spread to
distant sites (M0).

OR
T3, N0, M0

Thetumoris largerthan5 cm across but does notgrow into the

chest wall orskin (T3). Thecancerhas not spread to the
lymph nodes (N0)orto distant sites (M0).

Stage

T0 to T2, N2,

Thetumoris not morethan 5 cm across (orcannot be found)

IIIA

M0

(T0 to T2).It has spreadto 4 to 9 axillarylymph nodes, orit

has enlarged theinternalmammarylymph nodes(N2). The
cancerhasn't spread to distant sites (M0).
OR

T3, N1 or

Thetumoris largerthan5 cm across but does notgrow into the

N2, M0

chest wall orskin (T3).It has spread to 1 to 9 axillary nodes,

orto internal mammarynodes (N1 orN2). The cancer hasn't
spread to distant sites (M0).

Stage

T4, N0 to N2, Thetumorhasgrown into the chest wall orskin (T4), and

IIIB

M0

oneofthe followingapplies:
It has not spread to thelymph nodes (N0).
It has spread to 1 to 3 axillarylymph nodesand/ortiny
amounts of cancerare found in internal mammarylymph
nodes on sentinel lymphnodebiopsy(N1).
It has spread to 4 to 9 axillarylymph nodes, orit has
enlarged theinternal mammarylymph nodes (N2).

The cancerhasn't spreadto distant sites (M0).

Inflammatory breast canceris classifiedas T4dand is at
least stageIIIB.Ifit hasspread to manynearbylymph nodes
(N3)it could bestageIIIC, and ifit has spread todistant lymph
nodes ororgans (M1)it would bestageIV.
Stage

any T, N3,

Thetumoris anysize (orcan't be found), and oneofthe

IIIC

M0

followingapplies:
Cancerhas spreadto 10 ormore axillarylymph nodes
(N3).
Cancerhas spreadto thelymph nodes underthecollar
bone (infraclavicularnodes) (N3).
Cancerhas spreadto thelymph nodes abovethecollar
bone (supraclavicularnodes) (N3).
Cancerinvolves axillarylymph nodes and has enlarged
theinternal mammarylymph nodes (N3).
Cancerhas spreadto 4 ormore axillarylymph nodes, and
tinyamounts ofcancer are found in internal
mammarylymph nodes on sentinel lymph nodebiopsy
(N3).
The cancerhasn't spreadto distant sites (M0).

Stage

any T, any N,

The cancercan be anysize (anyT) and mayormaynot

IV

M1

havespread to nearbylymph nodes (anyN).It has spread to

distant organs orto lymph nodes farfrom thebreast (M1).
Themost common sites ofspreadarethebones,

liver, brain, orlungs.

Thestagingsystem in this chart uses thepathologicstage.It is based on theresults of
physicalexam, biopsy, imagingtests, and theresults ofsurgery, when thebreast mass and
nearbylymph nodeshavebeen looked at underamicroscope. This is likelyto be more
accuratethan clinical staging, which onlytakes into account thetestsdonebefore surgery.
Ifyou haveanyquestions about thestageofyourcancer and what it mightmean inyour case,
besureto askyourdoctor.

DetailsoftheTNMstagingsystem
TheTNM stagingsystem classifies cancers basedon 3 areascalled theT,N, and M
categories:

T (primarytumor) categories
TheletterT followed byanumber from 0 to 4 describes themain (primary)tumor's size
and spread to theskin orto the chest wall underthebreast. HigherT numbers mean a
largertumor and/orwiderspread to tissues nearthebreast.
TX:Primarytumorcannot be assessed.
T0:No evidenceofprimarytumor.
Tis:Carcinomain situ (DCIS,LCIS, orPaget diseaseofthenipplewith no associated
tumormass)
T1 (includes T1a, T1b, and T1c):Tumoris 2 cm (3/4 of an inch)orlessacross.
T2:Tumoris morethan2 cm but not morethan 5 cm (2 inches)across.
T3:Tumoris morethan5 cm across.
T4 (includes T4a, T4b, T4c, and T4d):Tumorofanysizegrowinginto thechest wall
orskin. This includes inflammatorybreast cancer.

N(nearbylymph node) categories

TheletterN followed byanumber from 0 to 3 indicates whetherthecancerhas spread to
lymph nodes nearthebreast and, ifso, how manylymph nodes areaffected.
Lymph nodestagingforbreast canceris based onhow thenodes look underthe
microscope, and has changedas technologyhasevolved. Newermethodshavemadeit

possibleto find smaller and smallerdeposits of cancercells, but experts haven't been sure
how much thesetinydeposits of cancer cells affect outlook.
Its notyetclearhow much cancerin thelymph nodeis needed to seeachangein outlook
ortreatment. This is stillbeingstudied, but fornow, adeposit ofcancer cells must
contain at least 200 cells orbe at least 0.2 mm across (less than 1/100 of aninch) forit to
changetheN stage. Anareaofcancerspread thatis smallerthan 0.2 mm (or fewerthan
200 cells)doesn't changethestage, but is recordedwith abbreviations (i+ormol+)that
indicatethetypeofspecial test used to find thespread.
Ifthe areaof cancerspread is at least 0.2 mm (or200 cells), but still not largerthan 2 mm,
it is called amicrometastasis (onemm is about thesizeofthewidth ofagrain of rice).
Micrometastasesare counted onlyifthere aren'tanylarger areas ofcancerspread. Areas of
cancerspread largerthan 2 mm areknown to affect outlook and do changethe N stage.
Theselarger areas aresometimescalledmacrometastases, but aremoreoften just called
metastases.
NX:Nearbylymph nodes cannot be assessed (forexample, iftheywereremoved
previously).
N0:Cancerhas not spread to nearbylymph nodes.
N0(i+):Theareaofcancerspread contains less than 200 cells and is smallerthan 0.2
mm. The abbreviation"i+"means that asmall numberofcancer cells (called isolated
tumor cells)wereseen in routinestains orwhen aspecial typeofstainingtechnique,
called immunohistochemistry, was used.
N0(mol+):Cancercellscannot beseen in underarm lymph nodes (even usingspecial
stains), but traces ofcancer cells weredetected usingatechniquecalled RT-PCR. RTPCRis amoleculartest that can find verysmall numbers of cells. (This test is not often
used forfindingbreast cancercells in lymphnodes becausetheresults do not
influencetreatment decisions.)
N1:Cancerhas spread to1 to 3 axillary(underarm)lymph node(s), and/ortinyamounts of
cancerarefound in internal mammarylymph nodes (thosenearthebreast bone)on sentinel
lymph nodebiopsy.
N1mi:Micrometastases (tinyareas ofcancerspread)in 1 to 3 lymph nodesunderthe
arm. Theareas ofcancerspread in thelymph nodes are2 mm orless across(but at least
200 cancercells or0.2mm across).
N1a:Cancerhas spread to 1 to 3 lymph nodes underthearm with at least one areaof
cancerspreadgreaterthan 2 mm across.
N1b:Cancerhas spread to internal mammarylymph nodes, but this spreadcould only
be found on sentinel lymph nodebiopsy(it did not causethelymph nodes to become
enlarged).

N1c: Both N1a and N1bapply.

N2:Cancerhas spread to4 to 9 lymph nodes underthe arm, orcancerhas enlarged the
internal mammarylymphnodes (eitherN2aorN2b, but not both).
N2a:Cancerhas spread to 4 to 9 lymph nodes underthearm, with at least one areaof
cancerspread largerthan2 mm.
N2b:Cancerhas spread to oneormoreinternal mammarylymph nodes, causing
them to become enlarged.
N3:Anyofthefollowing:
N3a:either:
Cancerhas spreadto 10 ormore axillarylymph nodes, with at least oneareaof
cancerspreadgreaterthan 2mm, OR
Cancerhas spreadto thelymph nodes underthecollarbone (infraclavicularnodes),
with at least one areaofcancerspreadgreaterthan2mm.
N3b:either:
Canceris found in at least one axillarylymph node (with at least oneareaof cancer
spreadgreaterthan 2 mm) and has enlarged theinternal mammarylymph nodes, OR
Cancerhas spreadto 4 ormore axillarylymph nodes (with at least oneareaof cancer
spreadgreaterthan 2 mm), and tinyamounts of cancerare found in internal
mammarylymph nodes on sentinel lymph nodebiopsy.
N3c:Cancerhas spread to thelymph nodes abovethe collarbone(supraclavicularnodes)
with at least one areaofcancerspreadgreaterthan2mm.

M(metastasis) categories
TheletterM followed bya0 or1 indicates whetherthe cancerhas spread to distant
organs --for example, thelungs orbones.
MX:Distant spread (metastasis) cannot beassessed.
M0:No distant spread is found on x-rays(orotherimagingtests)orbyphysical exam.
cM0(i+):Small numbersof cancercells are foundin blood orbonemarrow(found
onlybyspecial tests), ortinyareas ofcancerspread (no largerthan 0.2 mm) arefound in
lymph nodes awayfrom thebreast.
M1:Cancerhas spread to distant organs(most often to thebones, lungs, brain, orliver).

Breast cancer survivalrates,bystage

Survival rates tellyou what portion ofpeoplewith thesametype and stageof cancer are still
alivea certain amount oftime (usually5years) aftertheywerediagnosed. Theycant tellyou
how longyou will live, but theymayhelpgiveyouabetterunderstanding about how likelyit is
thatyourtreatment will besuccessful. Somepeoplewill want to know the survival rates
fortheircancertypeand stage,andsomepeoplewont.Ifyou dont want to know,you dont
haveto.
Survival rates areoften used bydoctors as astandard wayofdiscussing aperson's outlook
(prognosis). Somewomen with breast cancermight want to know thesurvival statistics
forpeoplein similarsituations, whileothers might not find thenumbers helpful, ormight
even not want to know them.

Whatisa5-yearsurvivalrate?
Statistics on theoutlook fora certain type and stageof cancer areoftengiven as 5-year
survival rates, but manypeoplelivelonger often much longer than 5years. The5- year
survival rateis thepercentageofpeoplewho liveat least 5years afterbeing diagnosed
with cancer.For example, a5-yearsurvival rateof90%means that an estimated 90 out
of100 peoplewho havethat cancer arestill alive5yearsafterbeing diagnosed. Keep in
mind, however, that manyofthesepeoplelivemuch longerthan 5 years afterdiagnosis.
Relativesurvival rates areamoreaccuratewaytoestimatethe effect ofcanceron survival.
Theserates comparewomenwith breastcancerto women in theoverall population. For
example, ifthe5-year relativesurvival rate foraspecifictypeof canceris
90%, it means that peoplewho havethat cancerare, on average,about 90%as likelyas
peoplewho dont havethat cancerto live forat least 5years afterbeingdiagnosed.
But remember, the5-year relativesurvival ratesare estimates youroutlook can vary
based on anumberoffactors specifictoyou.

Survivalratesdonttellthewholestory
Survival rates areoften based on previous outcomes oflargenumbers ofpeoplewho had
thedisease, but theycant predict what will happen in anyparticularpersons case. There
areanumberoflimitations to remember:
Thenumbers beloware amongthemost current available. But toget 5-yearsurvival
rates, doctors haveto look at peoplewho weretreated at least 5years ago.As treatments
areimproving overtime, women who arenow beingdiagnosedwith breast
cancermayhaveabetteroutlook than thesestatistics show.

The availablestatistics forbreast cancerdo not dividesurvival rates byall ofthe

substages, such asIAandIB. Theratesforthesesubstagesarelikelyto becloseto
the rate fortheoverall stage. For example, thesurvival rate forstageIA is likelyto be
slightlyhigherthan that listed forstageI,whilethesurvival rateforstageIBwould
be expected to beslightlylower.
Thesestatistics arebasedon thestageofthecancerwhen it was first diagnosed. They do
not applyto cancers that later comeback orspread, for example.
Manyother factors affect aperson's outlook, suchas age and health, thepresenceof
hormone receptors on thecancercells, thetreatment received,and how well the
cancerresponds to treatment.
Yourdoctorcan tellyouhow thesenumbers mayapplytoyou, as heorsheis familiar
withyourparticularsituation.

5-yearrelativesurvivalratesforbreastcancerbystage
Theoutlook forwomenwith breast cancervariesbythestage (extent)ofthe cancer.In
general, thesurvival rates arehigherforwomenwith earlierstage cancers. But remember,
theoutlook for eachwoman is specificto her circumstances.
The5-yearrelativesurvival rate forwomen withstage0 orstageIbreast canceris
closeto 100%.
Forwomenwith stageIIbreast cancer, the5-yearrelativesurvival rateis about 93%.
The5-yearrelativesurvival rate forstageIIIbreast cancers is about 72%.But often,
women with thesebreast cancers can besuccessfullytreated.
Breast cancers that havespread to otherparts ofthebodyaremoredifficult to treat and
tend to haveapooreroutlook. Metastatic, orstageIV breast cancers, havea5yearrelativesurvival rateof about 22%. Still, there areoften manytreatment options
available forwomen with this stageofbreast cancer.
Remember, thesesurvival rates areonlyestimates theycant predict whatwill happen to
anyindividual person.Weunderstand that thesestatistics can be confusingand may
leadyou to havemorequestions. Talk toyourdoctorto betterunderstandyourspecific
situation.
Pleasenotethatthesestatisticscomefromthe NationalCancerInstitutesSEERdatabase.Theyarebased on
thepreviousversionofAJCCstaging.InthatversionstageII
alsoincludedpatientsthatwouldnowbe
consideredstageIB.

Howis breast cancer treated?

Ifyouvebeen diagnosedwith breast cancer,yourcancercareteam will discuss treatment
options withyou.Its important thatyou taketimeto think aboutyourchoices. You will want
to weigh thebenefits of each treatment option against thepossible risks and side effects.

Whichtreatmentsareusedforbreastcancer?
Thereareseveral ways totreat breast cancer, dependingon its typeand stage.
Local treatments:Sometreatments are called local therapies, meaningtheytreat the
tumorwithout affectingthe rest ofthebody. Types oflocal therapyused forbreast cancer
include:
Surgery
Radiation therapy
Thesetreatments aremorelikelyto beuseful forearlierstage(less advanced) cancers,
although theymight alsobeused in someothersituations.
Systemic treatments:Breast cancercanalso betreated usingdrugs, whichcan begiven
bymouth ordirectlyintothebloodstream. Thesearecalled systemictherapies because
theycan reachcancercells anywherein thebody.Dependingon thetypeofbreast cancer,
several different types ofdrugs might beused, including:
Chemotherapy
Hormonetherapy
Targeted therapy
Manywomen will get morethan onetypeoftreatment fortheircancer.

Howisbreastcancertypicallytreated?
Most women with breastcancerwill havesometypeofsurgeryto removethetumor.
Dependingon thetypeofbreast cancer and howadvanced it is,you mayneed othertypes
oftreatment as well, eitherbeforeoraftersurgery, orsometimes both. Surgeryis less likelyto
beamain part ofthetreatment formoreadvanced breast cancers.
Typical treatment plansarebased on thetypeofbreast cancer, its stage,andanyspecial
situations:
Non-invasivebreast cancer (DCISorLCIS)

Invasivebreast cancer(StagesI-IV)
Breast cancerduringpregnancy
Yourtreatment planwill depend on otherfactorsas well, includingyouroverall health
and personal preferences.

Whotreatsbreastcancer?
Doctors onyourcancertreatment team might include:
A breast surgeon: adoctorwho uses surgeryto treat breast cancer
A radiation oncologist: adoctorwho uses radiation to treat cancer
A medical oncologist: adoctorwho uses chemotherapyand othermedicines to treat
cancer
Manyotherspecialists might bepart ofyourtreatment team as well, includingphysician
assistants, nursepractitioners, nurses, psychologists, social workers, nutritionists, and
otherhealth professionals. SeeHealth Professionals AssociatedWith Cancer Carefor
moreon this.

Makingtreatmentdecisions
Its important to discussall ofyourtreatment options, includingtheirgoalsand possible side
effects, withyourdoctors to help makethedecision that best fitsyourneeds.Its also
veryimportant to ask questions ifthereis anythingyourenot sureabout. See What
shouldyou askyourcancer careteam about breast cancer? forideas.

Gettinga secondopinion
You mayalso want toget asecond opinion. This cangiveyou moreinformation and help
you feel morecertain about thetreatment planyouchoose.Ifyouarent surewhereto go
forasecond opinion, askyourdoctor forhelp. SeeSeeking a Second Opinion formore
information.

Thinking about takingpart inaclinicaltrial

Clinical trials are carefullycontrolledresearch studies that aredoneto get acloserlook at
promisingnew treatments orprocedures. Clinicaltrials areonewaytoget state-of-theart
cancertreatment.In some cases theymaybetheonlywaytoget access tonewer treatments.
Theyare alsothebest wayfordoctorsto learn bettermethods totreat cancer. Still, theyarenot
right for everyone.

Ifyou would liketo learnmore about clinical trialsthat might be right foryou, start by
askingyourdoctorifyour clinicorhospital conducts clinical trials. You can also call our
clinical trials matchingserviceat 1-800-303-5691foralist ofstudies that meetyour medical
needs, orseethe Clinical Trials section to learn more.

Consideringcomplementary and alternative methods

You mayhearabout alternativeor complementarymethods thatyourdoctorhasnt mentioned
to treatyourcanceror relievesymptoms. Thesemethods can includevitamins, herbs, and
special diets,orothermethods such asacupunctureormassage,to namea few.
Complementarymethods referto treatments that areused alongwithyour regular medical
care. Alternativetreatments areused instead ofadoctors medical treatment. Although
someofthesemethods might behelpful in relievingsymptoms orhelpingyou feel better,
manyhavenot been proven to work. Somemight even bedangerous.
Besureto talk toyour cancercareteam about anymethodyou arethinking about using.
Theycan helpyou learnwhat is known (ornot known) about themethod,which can help
you make an informed decision. SeetheComplementaryand AlternativeMedicine section
to learn more.

Choosingtostoptreatmentorchoosingnotreatmentatall
Forsomepeople, when treatments havebeen triedand areno longer controllingthe
cancer, it could betimeto weigh thebenefits andrisks of continuingto trynew treatments.
Whetherornotyou continuetreatment, there arestill thingsyou can do to help maintain
orimproveyourqualityoflife.Learn morein If Cancer Treatments Stop Working.
Somepeople, especiallyifthe canceris advanced,might not want to betreated at all.
Therearemanyreasons you might decidenot togetcancertreatment, but its important
to talk this through with yourdoctors beforeyoumakethat decision. Rememberthat even
ifyou choosenot to treatthe cancer,you can still get supportive careto helpwith pain or
othersymptoms.

Helpgettingthroughcancertreatment
Your cancercareteam will beyour first sourceofinformation and support,but there are
other resources forhelpwhenyou need it. Hospital-or clinic-based support services are an
important part ofyourcare.Thesemight includenursingorsocial workservices, financial
aid, nutritionaladvice, rehab, orspiritualhelp.
TheAmerican CancerSocietyalso has programs and services includingrides to
treatment, lodging, support groups,and more tohelpyouget through treatment. Call

ourNational CancerInformation Center at 1-800-227-2345 and speakwith oneofour

trained specialists on call 24 hours aday, everyday.
ThetreatmentinformationgivenhereisnotofficialpolicyoftheAmericanCancerSocietyandisnot
intendedasmedicaladvicetoreplacetheexpertiseandjudgmentofyourcancercareteam.Itisintended to
helpyou andyourfamilymakeinformeddecisions,togetherwithyourdoctor.Yourdoctormayhave
reasonsforsuggestingatreatmentplandifferentfromthesegeneraltreatmentoptions.Don'thesitateto
askhimorherquestionsaboutyourtreatmentoptions.

Surgeryforbreast cancer
Most women with breastcancerhavesometypeofsurgeryas part oftheirtreatment.
Dependingon thesituation, surgerymaybedonefordifferent reasons. Forexample,
surgerymaybedoneto:
Remove as much ofthe canceras possible (breast-conservingsurgeryormastectomy)
Find out whetherthecancerhas spread to thelymph nodes underthearm (sentinel
lymph nodebiopsyor axillarylymph nodedissection)
Restorethebreasts shape afterthecanceris removed (breast reconstruction)
Relievesymptoms of advancedcancer

Surgerytoremovebreastcancer
Therearetwo main typesofsurgeryto removebreast cancer:
Breast-conserving surgery (alsocalled alumpectomy, quadrantectomy, partial
mastectomy, or segmental mastectomy) in whichonlythepart ofthebreast
containingthecanceris removed. Thegoal is to removethe canceras wellas some
surroundingnormal tissue. How much ofthebreast is removed depends onthesize
and location ofthetumorand otherfactors. (SeeBreast-conservingsurgery
(lumpectomy).)
Mastectomy in which the entirebreast is removed, including all ofthebreast tissue
and sometimes othernearbytissues. Thereareseveral different types of
mastectomies. Somewomen mayalso get adoublemastectomy, in whichboth breasts
areremoved. (SeeMastectomy.)

Choosingbetweenbreast-conservingsurgeryand
mastectomy
Manywomen with early-stagecancerscan choosebetween breast-conservingsurgery
(BCS) and mastectomy.Themain advantageofBCSis that awoman keeps most ofher

breast. But in most casesshewill also need radiation. Women who havemastectomyfor
early-stage cancers areless likelyto need radiation.
Forsomewomen, mastectomymayclearlybeabetteroption, becauseofthetypeof breast
cancer, thelargesizeofthetumor, previoustreatment history, orcertain other factors.

Surgerytoremovenearbylymphnodes
To find out ifthebreast cancerhas spread to axillary(underarm)lymph nodes, oneor
moreoftheselymph nodes will be removedand looked at underthemicroscope. This is an
important part of figuringout thestage(extent)ofthe cancer.Lymph nodes can be removed
either as part ofthesurgeryto removethebreastcancerorinaseparate operation. To learn
moreabout theseproceduresand when theymight bedone, see Lymph
nodesurgeryforbreast cancer.

Breastreconstructionaftersurgery
Afterhaving amastectomy(orsomebreast-conservingsurgeries), awoman might want to
considerhavingthebreast mound rebuilt to restorethebreasts appearance after surgery.
This is called breast reconstruction.
Thereareseveral types of reconstructivesurgery,althoughyouroptions maydepend on
yourmedical situation and personal preferences. You mayhaveachoicebetween having
breast reconstruction at thesametime as themastectomy(immediate reconstruction)or at
alatertime (delayed reconstruction).
Ifyou arethinkingabouthavingreconstructivesurgery, its agood ideato discuss it with
yourbreast surgeon andaplasticsurgeon beforeyourmastectomy. This gives the
surgical team timeto plan out thetreatment options that might bebest foryou, even if
you wait and havethe reconstructivesurgerylater.
To learn about different breast reconstruction options, seeBreast Reconstruction After
Mastectomy.

Surgeryforadvancedbreastcancer
Although surgeryis veryunlikelyto curebreast cancerthat has spread to otherparts of
thebody, it can still behelpful in somesituations, either as awayto slow thespread of
the cancer, orto help prevent or relievesymptomsfrom it. For example, surgerymight be
used:
When thebreast tumoris causing an openwound in thebreast (or chest)

To treat asmall numberof areas ofcancerspread(metastases)in acertainpart ofthe

body, suchas thebrain
When an areaofcancerspread is pressingon thespinal cord
To treat ablockagein theliver
To provide reliefofpainorothersymptoms
Ifyourdoctorrecommends surgeryforadvancedbreast cancer, its important thatyou
understand its goalwhetherits to tryto curethecancerorto prevent ortreat symptoms.

Breast-conserving surgery(lumpectomy)
Breast-conservingsurgeryis sometimes called lumpectomy, quadrantectomy, partial
mastectomy, orsegmental mastectomy.In this surgery, onlythepart ofthebreast
containingthecanceris removed. Thegoal is to removethe canceras wellas some
surroundingnormal tissue. How much ofthebreast is removed depends onthesize and
location ofthetumor andother factors.

hocangetbreast-conservingsurgery?
Breast-conservingsurgery(BCS)is agood option formanywomen with early-stage cancers.
Themainadvantageis that awoman keeps most ofherbreast. However, shewill in most
cases also need radiation therapy. Womenwho havetheirentirebreast removed
(mastectomy) forearly-stagecancers areless likelyto need radiation, but theymaybe
referred toadoctorwhospecializes in radiation, called aradiation oncologist, for evaluation
becauseeachpatients canceris unique.
Most women and theirdoctors preferBCSand radiation therapywhen it'sa reasonable
option. BCSmight beagood option ifyou:
Areveryconcernedabout losing yourbreast
Arewillingto haveradiation therapyand abletoget to the appointments
Havenot alreadyhad thebreast treated with radiation therapyorBCS
Haveonlyoneareaofcanceron thebreast, ormultiple areas that arecloseenough
togetherto beremoved without changingthelookofthebreast too much
Haveasmall tumor (5cm [2 inches]orsmaller), and atumorthat is small relativeto
yourbreast size
Arenot pregnant or, ifpregnant, will not need radiation therapyimmediately(to
avoid riskingharm to the fetus)
Do not haveageneticfactorsuch as aBRCA mutation, which might increaseyour
chanceofasecond cancer

Do not havecertain serious connectivetissuediseases such as sclerodermaorlupus,

which maymakeyouespeciallysensitiveto theside effects ofradiation therapy
Do not haveinflammatorybreast cancer
Somewomen might beworried that havingaless extensivesurgerymight raisetheir risk
ofthe cancercomingback. But the fact is that in most cases, mastectomydoes not give you
anybetter chanceoflong-term survival orabetteroutcomefrom treatment. Studies
followingthousands ofwomen formorethan 20years show that when BCScan bedone,
havingmastectomyinstead does not provide anybetter chanceofsurvival.

WillI needbreastreconstructionsurgeryafterbreastconservingsurgery?
Beforeyoursurgery, talk toyourbreast surgeon about how breast-conservingsurgery
might changethelook ofyourbreast. Thelargertheportion ofbreast removed, themore
likelyit is thatyou will seeachangein theshapeofthebreast afterward.Ifyourbreasts

look verydifferent aftersurgery, it maybepossibleto havesometypeof reconstructive

surgeryorto havethesizeoftheunaffected breastreduced to makethebreasts more
symmetrical.It mayevenbepossibleto havethis doneduringtheinitial surgery.It's very
important to talk withyourdoctor (andpossiblyaplasticsurgeon)beforesurgerytoget an
ideaofhowyourbreasts arelikelyto look afterward, and to learn whatyouroptions might be.

Recoveringfrombreast-conservingsurgery:Whattoexpect
This typeofsurgeryis usuallydoneinan outpatient surgerycenter, andanovernight stay in
thehospital is usuallynot needed. Most womencan return to their regular activities within
2 weeks.
Ask amemberofyourhealth careteam how to careforyoursurgerysiteand arm.
Usually,youandyourcaregivers willget written instructions about care aftersurgery.
Theseinstructions should include:
How to care forthesurgerysiteand dressing
How to care foryourdrain, ifyou haveone(This is aplasticor rubbertubecoming out
ofthesurgerysitethat removes the fluid that collects duringhealing.)
How to recognizesigns ofinfection
Bathingand showeringaftersurgery
When to call thedoctorornurse
When to start usingthearm again and how to do arm exercises to prevent stiffness
When to start wearingabraagain
What to eat and not to eat
Useofmedicines, includingpain medicines and possiblyantibiotics
Anyrestrictions on activity
What to expect regarding sensations ornumbness in thebreast andarm
What to expect regarding feelings about bodyimage
When to seeyourdoctorfora follow-upappointment
Referral to aReach To Recoveryvolunteer. Through ourReach To Recovery
program, aspeciallytrained volunteerwho has hadbreast cancer can provide
information, comfort, and support.

Howcanthedoctorsbesureallofthecancerwasremoved?
Duringthesurgery, thesurgeon will tryto removeall ofthe cancer, plus some
surroundingnormal tissue.
Aftersurgeryis complete, adoctorcalled apathologist will useamicroscopeto look at
thetissuethat was removed.Ifthepathologist finds no cancercells at anyofthe edges of the
removed tissue, it is said to havenegativeorclear margins. But ifcancer cells are foundat
the edges ofthetissue, it is said to havepositivemargins.
Thepresenceofpositivemargins means that somecancercells mayhavebeen left behind
aftersurgery, so thesurgeon mayneed togo backand removemoretissue.This operation is
called are-excision.Ifthesurgeon can't removeenough breast tissuetoget clear surgical
margins, amastectomymaybeneeded.
Thedistancefrom thetumorto themargin is also important. Even ifthemargins are
clear,theycould beclosemeaningthedistancebetween theedgeofthetumor and
edgeofthetissueremoved is too small and moresurgerymaybeneeded. Surgeons
sometimes disagreeon what is an adequate (orgood)margin.

Willmoretreatmentbeneededafterbreast-conserving
surgery?
Most women will need radiation therapyto thebreast afterbreast-conservingsurgery.
Sometimes, to makeit easierto aim the radiation,small metallic clips (which will show
up on x-rays)maybeplaced insidethebreast duringsurgeryto mark thearea.
Manywomen receivehormonetherapyaftersurgeryto help lowerthe riskofthe cancer
comingback. Somewomen might also need chemotherapyaftersurgery.Ifso, radiation
therapyis usuallydelayed until the chemotherapyis completed.

Sideeffectsofbreast-conservingsurgery
Side effects ofbreast-conservingsurgerycan include:
Pain ortenderness
Temporaryswelling
Hard scartissuethat forms in thesurgical site
Changein theshapeofthebreast
Nerve(neuropathic)painin the chest wall, armpit,and/or arm that doesnt go away
overtime (called post-mastectomypain syndromeorPMPS)

As with all operations, bleedingand infection at thesurgerysitearealso possible.If

axillarylymph nodesarealso removed, othersideeffects such as lymphedemamay
occur.

Mastectomy
Mastectomyis surgerytoremovethe entirebreast.All ofthebreast tissueisremoved,
sometimes alongwith othernearbytissues.

Typesofmastectomies
Thereareseveral different types ofmastectomies,based on how thesurgeryis doneand
how much additional tissueis removed.

Simple (or total) mastectomy

Simplemastectomyis themost common typeofmastectomyused to treatbreast cancer. In
this procedure, thesurgeonremoves theentirebreast, includingthenipple, but does not
removeunderarm lymph nodes ormuscletissue from beneath thebreast. (Sometimes
lymph nodes areremoved in adifferent procedureduringthesamesurgery.)Most women,
iftheyarehospitalized, cango homethenext day.

Double mastectomy
Ifamastectomyis doneon both breasts, it is called adouble (orbilateral)mastectomy.
When this is done, it is often as preventivesurgeryforwomen at veryhighrisk for
gettingcancerin theotherbreast, suchas thosewith aBRCA genemutation.

Skin-sparingmastectomy
Forsomewomenconsideringimmediate reconstruction, askin-sparingmastectomycan
bedone.In this procedure, most oftheskin overthebreast (otherthan thenipple and areola)is
left intact. This can workas well asasimplemastectomy. Theamount ofbreast tissue
removed is thesame as with asimplemastectomy.
Implants ortissuefrom otherparts ofthebodyareused to reconstruct thebreast.
Skin-sparingmastectomymaynot besuitableforlargertumors orthosethat are closeto
thesurfaceoftheskin. This approach has not been used for as longas themorestandard
typeofmastectomy, butmanywomen preferit becauseit offers the advantageofless
scartissue anda reconstructed breast that seemsmorenatural.

Modified radicalmastectomy
A modified radical mastectomycombinesasimplemastectomywith theremoval ofthe
lymph nodes underthe arm (called an axillarylymph nodedissection).

Nipple-sparingmastectomy
Nipple-sparingmastectomyis avariation oftheskin-sparingmastectomy.It is moreoften an
option forwomen who haveasmall, early-stage cancerneartheouterpart ofthe
breast, with no signs ofcancerin theskin ornearthenipple. (Cancercells aremorelikely to
behidden in thenippleifthebreast tumoris largeror closeto thenipple,which means thereis
ahigherrisk thecancerwill comeback ifthenippleis not removed.)
In this procedure, thebreast tissueis removed, but thebreast skin and nipple areleft in
place. This is followed bybreast reconstruction. Thesurgeon often removes thebreast
tissuebeneath thenipple(and areola)duringtheproceduretocheckforcancercells.If canceris
found in this tissue, thenipplemust be removed. Even when nocanceris found
underthenipple, somedoctors givethenippletissueadoseofradiation duringorafter
thesurgeryto tryto reducethe risk ofthecancercomingback.
Therearestill someproblems with nipple-sparing surgeries. Afterward, thenippledoes
not haveagood blood supply, so sometimes it canwither awayorbecomedeformed.

Becausethenervesarealso cut, thereis littleorno feelingleft in thenipple.Forwomen with

largerbreasts, thenipplemaylook out ofplace afterthebreast is reconstructed. As a result,
manydoctors feelthat this surgeryis best donein women with small to medium sized
breasts. This procedureleaves less visiblescars, but ifit isn't doneproperly, it can
leavebehind morebreast tissuethan other forms ofmastectomy. This couldresult in a
higherrisk ofcancerdevelopingthan foraskin-sparingorsimplemastectomy. This was
moreofaproblem in thepast, but improvements in techniquehavehelpedmakethis
surgerysafer. Still, manyexperts do notyet considernipple-sparingprocedures a
standard treatment forbreast cancer.

Radicalmastectomy
In this extensiveoperation, thesurgeon removes the entirebreast, axillary(underarm)
lymph nodes, and thepectoral (chest wall)muscles underthebreast. This surgerywas
onceverycommon, but less extensivesurgery(such as modified radical mastectomy)has
been found to bejust as effectiveand with fewerside effects, so this surgeryis rarely
donenow. This operation maystill bedone forlargetumors thataregrowinginto the pectoral
muscles.

Whoshouldgetamastectomy?
Manywomen with early-stagecancerscan choosebetween breast-conservingsurgery
(BCS) and mastectomy.You mayhavean initial gut preference formastectomyas away to
"takeit all out as quicklyas possible." But thefact is that in most cases,mastectomy does
not giveyouanybetter chanceoflong-termsurvival orabetteroutcome from treatment.
Studies followingthousands ofwomenformorethan 20years show that when BCScan
bedone, doing mastectomyinstead doesnot provide anybetterchanceof survival.
Although most women and theirdoctors preferBCS(with radiation therapy)when it's a
reasonableoption, therearecases wheremastectomyis likelyto bethebest choice. For
example, mastectomymight berecommended ifyou:
Areunableto haveradiation therapy, orwould preferamore extensivesurgeryto
havingradiation therapy
Have alreadyhad thebreast treated with radiation therapy
Have alreadyhad BCSalongwith re-excision(s)that havenot completelyremoved the
cancer
Havetwo ormoreareasof cancerin thesamebreast that arenot closeenough
togetherto beremoved without changingthelookofthebreast too much

Havealargertumor(greaterthan 5 cm [2 inches]across), oratumorthat is large

relativetoyourbreast size
Arepregnant and wouldneed radiation therapywhilestill pregnant (riskingharm to
the fetus)
Haveageneticfactorsuch as aBRCA mutation, which might increaseyourchanceof
asecond cancer
Havecertain serious connectivetissuediseases such as sclerodermaorlupus, which
maymakeyou especiallysensitiveto theside effects of radiation therapy
Haveinflammatorybreast cancer
Forwomenwho areworried about breastcancerrecurrence, it is important to understand
that having amastectomyinstead ofbreast-conservingsurgeryplus radiation onlylowers
yourrisk ofdevelopingasecond breast cancerin thesamebreast.It does not lowerthe
chanceofthecancer comingback in otherparts ofthebody.

ShouldI havebreastreconstructionsurgeryafter
mastectomy?
Afterhaving amastectomyawoman might want to considerhavingthebreast mound
rebuilt to restorethebreast's appearanceaftersurgery. This is called breast reconstruction.
Althougheachcaseis different, most mastectomypatientscan have reconstruction.
Reconstruction can bedone at thesametime as themastectomyoryears later.
Ifyou arethinkingabouthavingreconstructivesurgery, its agood ideato discuss it with
yoursurgeon andaplasticsurgeon beforeyourmastectomy.This allows thesurgical teams to
plan thetreatment thats best foryou, even ifyou wait and havethe
reconstructivesurgerylater.Insurancecompanies typicallycoverbreast reconstruction,
butyou should check withyourinsurance companysoyou know what is covered.
Somewomen choosenotto have reconstruction surgery. Wearing abreast prosthesis (breast
form)is anotheroption forwomen who want to havethe contourofabreast under their
clothes without havingsurgery. Somewomenare alsocomfortablewith just going
flatifboth breasts wereremoved.

Recoveringfromamastectomy:Whattoexpect
Ingeneral, women havingamastectomystayin thehospital for1 or2 nights and thengo
home. However, somewomen maybeplaced in a23-hour, short-stayobservation unit
beforegoinghome.Howlongit takes to recover from surgerydepends onwhat procedures
weredone. Most women can return to their regular activities within 4 weeks.

Recoverytimeis longerifbreast reconstruction was done as well, and it can takemonths to

return to full activityaftersomeprocedures.
Ask amemberofyourhealth careteam how to care foryoursurgerysiteand arm.
Usually,youandyourcaregivers willget written instructions about care aftersurgery.
Theseinstructions should include:
How to care forthesurgerysiteand dressing
How to care foryourdrain, ifyou haveone(this is aplasticor rubbertubeto coming out
ofthesurgerysitethat removes the fluid that collects duringhealing)
How to recognizesigns ofinfection
Bathingand showeringaftersurgery
When to call thedoctorornurse
When to start usingthearm again and how to do arm exercises to prevent stiffness
When to start wearingabraagain
When to begin using aprosthesis and what typeto use
What to eat and not to eat
Useofmedicines, includingpain medicines and possiblyantibiotics
Anyrestrictions on activity
What to expect regarding sensations ornumbness in thebreast andarm
What to expect regarding feelings about bodyimage
When to seeyourdoctorfora follow-upappointment
Referral to aReach To Recoveryvolunteer. Through ourReach To Recovery
program, aspeciallytrained volunteerwho has hadbreast cancer can provide
information, comfort, and support.

Willmoretreatmentbeneededaftermastectomy?
Somewomen mightgetothertreatments afteramastectomy, such as radiation therapy,
hormonetherapy,chemotherapy, ortargeted therapy. Talk toyourdoctorabout what to
expect.

Sideeffectsofmastectomy
To some extent, theside effects ofmastectomycan depend on thetypeofmastectomy you
have (with moreextensivesurgeries tendingto havemoresideeffects). Side effects can
include:
Pain ortenderness
Swellingat thesurgerysite
Buildup ofblood in thewound (hematoma)
Buildup of clear fluid in thewound (seroma)
Limited arm orshouldermovement
Numbness in the chest orupper arm
Nerve(neuropathic)painin the chest wall, armpit,and/or arm that doesnt go away
overtime (called post-mastectomypain syndromeorPMPS)
As with all operations, bleedingand infection at thesurgerysitearealso possible.If
axillarylymph nodesarealso removed, othersideeffects such as lymphedemamay
occur.

Lymph node surgeryforbreast cancer

Ifyou havebeen diagnosed with breast cancer, its important to find out how farthe
cancerhas spread. To help find out ifthe cancerhas spread beyond thebreast, oneor
moreofthelymph nodesunderthearm (axillarylymph nodes)are removed and checked
underamicroscope. Thisis an important part ofstaging. When thelymph nodes contain
cancercells, thereis ahigher chancethatcancercells have also spread to otherparts of
thebody. Treatment decisions will often depend on whethercanceris found in thelymph
nodes.
Lymph noderemoval can bedonein different ways, dependingon whether anylymph
nodes areenlarged, howbigthebreast tumoris, and other factors.

Biopsyofanenlargedlymphnode
Ifanyofthelymph nodes underthe arm or around the collarboneareswollen, theymay be
checked for cancerspread directlywith aneedlebiopsy(eitherafineneedle aspiration
biopsyoracoreneedlebiopsy).Less often, the enlarged nodeis removedwith surgery.If
canceris found in thelymph node, morenodes will need to be removed duringan
axillarylymph nodedissection (described below).

Typesoflymphnodesurgery
Even ifthenearbylymphnodes arenotenlarged, theywill still need to be checked for
cancer. This can bedonein two different ways. Sentinel lymph nodebiopsyis themost
common and least invasiveway, but in some cases amore extensive axillarylymph node
dissection might beneeded.
Lymph nodesurgeryis often done as part ofthemain surgeryto removethebreast
cancer, but in some casesit might bedone as aseparateoperation.

Sentinellymph nodebiopsy(SLNB)
Inasentinel lymph nodebiopsy(SLNB), thesurgeon finds and removes the first lymph
node(s)to whichatumoris likelyto spread(called thesentinel nodes). Todo this, the
surgeon injects aradioactivesubstance and/orabluedyeinto thetumor, the areaaround it,
orthe area around thenipple.Lymphaticvessels will carrythesesubstances alongthe
samepath that thecancerwould belikelyto take.The first lymph node(s)thedyeor
radioactivesubstancetravels to will bethesentinel node(s).

Afterthes

ubstancehas been injected, thesentinelnode(s)can be foundeitherbyusing a special

deviceto detect radioactivityin thenodesthat theradioactivesubstance flows
into, orbylooking forlymph nodes that haveturned blue. To double check, both methods
areoften used. Thesurgeon cuts theskin overtheareaand removes thenode(s)
containingthedyeorradiation.
The removed lymph nodes (often 2 or3 nodes)arethen checkedcloselyfor cancercells
byadoctorcalled apathologist. This is sometimes doneduringthesurgery. This way, if
canceris found in thesentinel lymph node(s), thesurgeon maydo afull axillary dissection
(ALND)to removemorelymph nodes.Ifno cancercells areseen in the node(s) at
thetimeofthesurgery, orifthesentinel node(s) arenot checked bya pathologist at
thetimeofthesurgery, theywill be examined more closelyoverthenext several days.
Ifcanceris found in thesentinel node(s)later, thesurgeon mayrecommenda full ALND at
alatertimeto check morenodes for cancer. Recently, however, studies haveshown that in
some cases it maybejust as safeto leavethe rest ofthelymph nodes behind. This is based
on certain factors, such as thesizeofthebreast tumor, what typeofsurgeryis used to
removethetumor, and what treatment is planned aftersurgery.Based on the studies that
havelookedat this, skippingtheALND maybe an option forwomen with tumors 5 cm (2
inches)orsmallerwho arehaving breast-conservingsurgeryfollowed by radiation.
Becausethis hasnt been studied well in women who havehad mastectomy, it isnt
clearthat skippingtheALND would besafeforthem.
Ifthereis nocancerin thesentinel node(s), it's veryunlikelythat thecancerhas spread to
otherlymph nodes, so nofurtherlymph nodesurgeryis needed.

Although SLNBhas becomea common procedure, it requires agreat dealofskill.It

should bedoneonlybyasurgeon who hasexperiencewith this technique.Ifyouare
thinkingabout havingthis typeofbiopsy,askyourhealth careteam iftheydo them
regularly.

Axillarylymph node dissection (ALND)

In this procedure, anywherefrom about 10 to 40 (though usuallyless than20)lymph nodes
areremovedfromthe areaunderthe arm (axilla) and checked for cancerspread. ALND is
usuallydone atthesametime as amastectomyorbreast-conservingsurgery( BCS), but it can
bedonein asecond operation. This was oncethemost common wayto check to seeifbreast
cancerhad spread to nearbylymph nodes, and it is still sometimes needed.For example, an
ALND maybedoneifaprevious biopsyhas shown oneormore oftheunderarm lymph nodes
havecancercells.

Sideeffectsoflymphnodesurgery
As with anyoperation, pain, swelling, bleeding,bloodclots, and infectionarepossible.

Lymphedema
A possiblelong-term effect oflymph nodesurgeryis swellingin the arm or chest called
lymphedema.Because anyexcess fluid in thearms normallytravels backinto the
bloodstream through thelymphaticsystem, removingthelymph nodes sometimes blocks

drainagefrom thearm, causingthis fluid to build up.

This is less common afterasentinel lymph nodebiopsy(SLNB)thanan axillarylymph

nodedissection (ALND).
Up to 30%ofwomen who haveALND develop lymphedema.It also occursin up to 3%
ofwomen who haveSLNB.It maybemore common if radiation is givenaftersurgery.
Sometimes theswellinglasts foronlyafew weeksand thengoes away. Othertimes, it lasts
alongtime.Ifyourarm is swollen, tight, orpainful afterlymph nodesurgery, be sureto tell
someoneonyour cancercareteam right away.

Limited armand shoulder movement

You might also havelimitedmovementinyourarmandshoulderaftersurgery. This is more
common afterALND than SLNB. Yourdoctormay giveyou exercises to help keep you
from havingpermanent problems (afrozen shoulder).
Somewomen noticea rope-likestructurethat begins underthe arm andcan extend down
toward the elbow. This issometimes called axillary websyndromeorlymphatic
cording.It is more common afterALND than SLNB. Symptoms maynot appearfor weeks
oreven months aftersurgery.It cancausepain and limit movement ofthe arm and

shoulder. This oftengoesawaywithout treatment,although somewomen mayfind

physical therapyhelpful.

Numbness
Numbness oftheskin ontheupper, innerarm is another common side effect becausethe
nervethat controls sensation heretravels through thelymph nodearea.

Radiation therapyfor breast cancer

Somewomen with breastcancerwill needradiation, often in addition to othertreatments.
Theneedforradiation depends on what typeofsurgery you had,whetheryourcancerhas
spread to thelymph nodes orsomewhere elseinyourbody,and in some cases,yourage. You
mayhavejust onetypeof radiation, ora combination ofdifferent types.
Radiation therapyis treatment with high-energyrays(such as x-rays)orparticles that
destroycancercells. There are2 main types ofradiation therapythat can beused to treat
breast cancer:
External beamradiation:This typeofradiationcomes from amachineoutsidethe
body.
Internal radiation(brachytherapy):Forthis treatment, a radioactivesourceis put
insidethebodyforashort time.

Whenmightradiationtherapybeused?
Women with breast cancermaybetreatedwith radiation in several situations:
Afterbreast-conservingsurgery(BCS), to help lowerthe chancethat thecancerwill
comeback in thebreast ornearbylymph nodes
Afteramastectomy, especiallyifthecancerwas largerthan 5cm (about 2 inches), or if
canceris found in thelymph nodes
Ifcancerhas spread to otherparts ofthebody, such as thebones orbrain

Externalbeamradiation
This is themost commontypeofradiation therapyforwomen with breast cancer.The
radiation is focused fromamachineoutsidethebodyon thearea affected bythecancer.
Which areas need radiation depends on whethermastectomyorbreast-conservingsurgery
(BCS)was done and whetherornot lymph nodes areinvolved.

Ifyou had amastectomyand no lymph nodes hadcancer, radiation is targeted at the

chest wall and theplaceswhereanydrainsexited thebodyaftersurgery.
Ifyou hadBCS,you willmost likelyhaveradiation on the entirebreast, and an extra
boost of radiation to the areain thebreast wherethe cancerwas removed to help
prevent it from comingback in that area. Theboost is often given afterthetreatments to
thewholebreast haveended.It uses thesamemachine, but thebeams are aimed at
theplacewherethe cancerwasremoved. Most women dont noticedifferent side effects
from boost radiation than from wholebreast radiation.
Ifcancerwasfound in thelymph nodes underthearm (axillarylymph nodes), radiation
maybegiven tothis area as well.In some cases, the areatreatedmayalso
includethenodes abovethe collarbone(supraclavicularlymph nodes) and thenodes
beneath thebreast bonein the centerofthe chest (internal mammarylymphnodes).

WhenwillI get radiation therapy?

Ifyou will need externalradiation therapyaftersurgery, it is usuallynot started until the
tissues havebeenabletoheal, often amonth orlonger.Ifyouaregetting chemotherapy as
well, radiation treatments areusuallydelayed until chemotherapyis complete.

Preparingfor externalbeamradiation therapy

Beforeyourtreatments start, the radiation team will take careful measurements to figure
out the correct angles foraimingtheradiation beams and theproperdoseof radiation.
Theywill makesomeinkmarks orsmall tattoos onyourskin to beused asaguideto focus the
radiation on the right area. Check withyourhealth careteam whetherthemarks theyusewill
bepermanent.
Lotions, powders, deodorants, and antiperspirants can interferewith external beam
radiation therapy, soyourhealth careteam maytellyou not to usethem until treatments are
complete.
External radiation therapyis much likegettingan x-ray, but theradiation is stronger. The
procedureitselfis painless. Each treatment lasts onlyafew minutes, but thesetup time
gettingyou into placefortreatmentusuallytakeslonger.

Types andschedulesof externalbeamradiation

Thetraditional scheduleforgettingbreast radiation has been 5 daysaweek(Monday
throughFriday)forabout 5 to 6 weeks. But manydoctors arenow usingaccelerated
breast irradiation to givelargerdoses overashortertime. There areseveraldifferent
types ofaccelerated breast irradiation:

Hypofractionatedradiationtherapy:In this approach, radiation is given in larger

doses usingfewertreatments typicallyforonly3 weeks.In women treated with
breast conservingsurgery(BCS) and without cancerspread to underarm lymph
nodes, this schedulehasbeen shown to bejust asgood at keepingthecancer from
comingback in thesamebreast asgivingtheradiation over5 weeks.It might also lead
to fewershort-termside effects. Newer approaches now beingstudied give radiation
overan even shorterperiod oftime.In one approach, largerdosesof radiation aregiven
eachday, but thecourseof radiation is shortened to only5 days.
Intraoperativeradiationtherapy (IORT):In this approach,asinglelargedoseof
radiation is given in theoperatingroom right afterBCS(beforethebreast incision is
closed).IORT requires special equipment and is not widelyavailable.
3D-conformal radiotherapy:In this technique, the radiation isgiven withspecial
machines so that it is better aimed at theareawherethetumorwas. This allows more
ofthehealthybreast to bespared. Treatments aregiven twiceadayfor5 days.
Becauseonlypart ofthebreast is treated, this is considered to beaform of accelerated
partial breastirradiation. (Other formsof accelerated partial breast irradiation
aredescribedunderBrachytherapy.)
Researchers hopetheseapproacheswill proveto be at least equal to the current, standard
radiation therapymethods, but few studies have compared them directlytostandard
radiation therapy.It is not known if all ofthenewermethods will havethesamelong- term
results as standard radiation, so not all doctors usethem. Women who areinterested in
these approaches maywant to ask theirdoctorabout takingpart in clinical trials of
accelerated breast irradiation now goingon.

Possible side effectsof externalradiation

Themain short-term sideeffects of external beam radiation therapyto thebreast are:
Swellingand heaviness in thebreast
Skin changes in thetreated area
Fatigue
Skin changes canrangefrom mild redness to blistering and peeling. Yourhealth care
team mayadviseyou to avoid exposingthetreatedskin to thesun becauseit maymake
theskin changes worse.Most skin changes get betterwithin a few months.Changes to
thebreast tissueusually go awayin 6 to 12 months, but it can takelonger.
External beam radiation therapycan also causeside effects lateron:
Somewomen mayfind that radiation therapycauses thebreast to becomesmaller and
firmer.

Radiation mayaffectyouroptions forbreast reconstruction lateron.It can also raise the

risk ofproblems ifits given afterreconstruction, especiallytissue flap procedures.
Women who havehad breast radiation mayhaveproblems breastfeedinglateron.
Radiation to thebreast can sometimes damagesomeofthenerves to the arm. This is
called brachial plexopathyand can lead to numbness, pain, and weakness in the
shoulder, arm and hand.
Radiation to theunderarm lymph nodes cancauselymphedema, atypeofpain and
swellingin thearm or chest.
Inrare cases, radiation therapymayweaken the ribs, which could lead to afracture.
In thepast, parts ofthelungs and heart weremorelikelytoget someradiation, which
could lead to long-term damageoftheseorgans insomewomen. But modern radiation
therapyequipment allows doctors to better focus theradiation beams, so
theseproblems are raretoday.
A veryrarecomplication of radiation to thebreastis thedevelopment of another
cancercalled angiosarcoma. Theserarecancerscan grow and spread quickly.

Brachytherapy
Brachytherapy, also known as internal radiation, is anotherwayto deliverradiation
therapy.Instead of aimingradiation beamsfrom outsidethebody, adevicecontaining
radioactiveseeds orpellets is placed into thebreast tissuein the areawherethe cancer
had been forashort time.
Forwomenwho had breast conservingsurgery(BCS), brachytherapycan beused along
with external beam radiation as awayto addan extraboost of radiation to thetumorsite. It
mayalso beused byitself (instead ofradiation to thewholebreast) as aform of accelerated
partial breast irradiation. Tumorsize,location, and otherfactors maylimit who canget
brachytherapy.

Types of brachytherapy
Therearedifferent typesofbrachytherapy:
Interstitial brachytherapy:In this approach, several small, hollow tubes called
catheters areinserted into thebreast around theareawherethecancerwasremoved and
areleft in placeforseveral days. Radioactivepellets areinserted into the
cathetersforshort periods oftime each dayand then removed. This methodof
brachytherapyhas been around longer(and has more evidenceto support it), but it is
not used as much anymore.

Intracavitary brachytherapy:This is themost common typeofbrachytherapyfor

women with breast cancer. A deviceis put into thespaceleft from BCSandis left in
placeuntil treatment is complete. Thereareseveral different devices thatcan beused,
includingMammoSite, SAVI,Axxent, and Contura. Theyallgo intothe
breast as asmall catheter(tube). Theend ofthedeviceinsidethebreast is then expanded
so that it stayssecurelyin the right place fortheentiretreatment. Theother end
ofthecathetersticksout ofthebreast.Foreach treatment, oneormoresources of radiation
(often pellets)is placed down through thetube and into thedevice fora
short time and then removed. Treatments aretypically given twiceadayfor5 daysas an
outpatient. Afterthelast treatment, thedeviceis collapsed down againand removed.
Earlystudies ofintracavitarybrachytherapyas theonlyradiation afterBCShavehad
promisingresults, but theydidnt directlycomparethis techniquewith standard whole
breast external beam radiation.
Onestudythat comparedoutcomes afterBCSfound that women treatedwith
brachytherapyweremorelikelytogo on to get amastectomyofthetreated breast (most
likelybecausecancerwas found again in that breast). Theoverall risk wasstill low,
however,with about 4%ofthewomen in thebrachytherapy group needing mastectomy
versus only2%ofthewomen in thewholebreast radiation group. Morestudies
comparingthe2 approaches areneeded to seeifbrachytherapyshould beused instead of
wholebreast radiation.

Possible side effectsof intracavitarybrachytherapy

As with external beam radiation, intracavitarybrachytherapycan havesideeffects,
including:
Redness
Bruising
Breast pain
Infection
Break-down of an areaoffat tissuein thebreast
Weakness and fractureofthe ribs in rarecases
Formoreinformation about radiation therapy, seetheRadiation Therapysection ofour
website.

Chemotherapyfor breastcancer
Somewomen with breastcancerwill get chemotherapy. Chemotherapytreats awomans
wholebodyforbreast cancer, not just herbreast.Manydifferent side effects arepossible
from taking chemotherapydrugs, but not all women get thesameones.
Chemotherapy(chemo)is treatment with cancer-killingdrugs that maybegiven
intravenously(injected into avein)orbymouth. Thedrugs travel through the
bloodstream to reach cancercells in most parts ofthebody.

Whenischemotherapyused?
Not all women with breast cancerwill need chemo, but there areseveral situations in
which chemo maybe recommended:
Aftersurgery(adjuvant chemotherapy):When chemo is givenafterbreast surgery, it
is called adjuvant chemotherapy. Surgeryis usedto remove all ofthecancerthat
can beseen, but adjuvantchemo is used to tryto kill anycancer cells thatmayhave been
left behind orspread but can't beseen,evenon imagingtests.Ifthesecells were allowed
to grow, theycould form new tumors in otherplaces in thebody.Adjuvant chemo
canreducethe risk ofbreast cancer comingback.
Beforesurgery (neoadjuvant chemotherapy):In neoadjuvant chemotherapy,you
get thetreatments beforesurgeryinstead of after.In terms ofsurvival and the cancer
comingback, thereis no differencebetweengettingchemo beforeoraftersurgery. But
neoadjuvantchemo can havesomebenefits. First, chemo mayshrink thetumor so that
it can be removedwith less extensivesurgery.Becauseofthis, neoadjuvant chemo is
often used to treat cancers that aretoo bigto beremoved at thetimeof
diagnosis (called locallyadvancedcancer).Also, by givingchemo beforethetumoris
removed, doctorscan betterseehow the cancerresponds to it.Ifthe first set of chemo
drugs does not shrink thetumor,yourdoctorwill know that otherdrugs areneeded.
Foradvanced breast cancer:Chemo can beused as themain treatment forwomen
whose cancerhas spreadoutsidethebreast and underarmarea, eitherwhenit is
diagnosed orafterinitial treatments. Thelength oftreatment depends on whetherthe
cancershrinks, how much it shrinks, and how wellyou toleratethe chemo.

Whichchemotherapydrugsareusedforbreastcancer?
In most cases (especiallyas adjuvant orneoadjuvant treatment), chemo ismost effective
when combinations ofmorethan onedrugareused. Today,doctors usemanydifferent
combinations, and it's not clearthat anysinglecombination is clearlythebest.
Themost common drugsused for adjuvant and neoadjuvant chemo include:

Anthracyclines, such as doxorubicin (Adriamycin) and epirubicin (Ellence)

Taxanes, such as paclitaxel (Taxol) and docetaxel (Taxotere)
5-fluorouracil (5-FU)
Cyclophosphamide (Cytoxan)
Carboplatin (Paraplatin)
Most often, combinations of2 or3 ofthesedrugsareused together.

Chemotherapyfor advanced breast cancer

Chemo drugs useful in treating women with breast cancerthat has spread, include:
Docetaxel
Paclitaxel
Platinum agents (cisplatin, carboplatin)
Vinorelbine (Navelbine)
Capecitabine(Xeloda)
Liposomal doxorubicin (Doxil)
Gemcitabine (Gemzar)
Mitoxantrone (Novantrone)
Ixabepilone(Ixempra)
Albumin-bound paclitaxel (nab-paclitaxel orAbraxane)
Eribulin (Halaven)
Although drug combinations areoftenused to treat earlybreast cancer,advanced breast
canceris moreoften treated with single chemo drugs. Still, some combinations, such as
carboplatin orcisplatin plus gemcitabineare commonlyused to treat advanced breast
cancer.
Oneormoredrugs that target HER2 maybeusedwith chemo fortumors that areHER2positive (See Targeted therapyforbreast cancerformoreinformation about these drugs.)

Howischemotherapygiven?
Chemo drugs forbreast canceraretypically giveninto avein (IV),either asan injection
overafew minutes or asan infusion overalongerperiod oftime. This canbedonein a
doctors office, chemotherapyclinic, orin ahospital setting.

Chemo is given in cycles, with each period oftreatment followed bya restperiod to give
thebodytimeto recoverfrom the effects ofthedrugs. Cyclesaremost often 2 or3 weeks long.
Chemo begins on the first dayofeachcycle, but theschedulevariesdependingon thedrugs
used. For example, with somedrugs, thechemo is given onlyon the first dayof thecycle.
With others, it is given forafew days ina row, oronceaweek. Then, at the
end ofthecycle, the chemo schedule repeats to start thenext cycle.
Adjuvant and neoadjuvant chemo is oftengiven foratotal of3 to 6 months, depending
on thedrugs that areused. Treatment maybelonger foradvanced breast cancerand is
based on how well it is workingand what sideeffectsyou have.

Dose-dense chemotherapy
Doctors havefound thatgivingthecycles ofcertain chemo drugs closertogethercan
lowerthe chancethat thecancerwill comeback and improvesurvival forsomewomen. For
example, adrugthat would normallybegivenevery3 weeks might begivenevery2 weeks.
This approachcan beused forneoadjuvant and adjuvant treatment.It can lead to
moreproblems with low blood cell counts, so its not an option for all women.

Possiblesideeffectsofchemoforbreastcancer
Chemo drugscan causeside effects, dependingonthetypeand doseofdrugsgiven,and
thelength oftreatment. Someofthemost common possibleside effects include:
Hairloss and nail changes
Mouth sores
Loss ofappetiteorincreased appetite
Nauseaand vomiting
Chemo can affect theblood-formingcells ofthebonemarrow,which can lead to:
Increased chanceofinfections (from low whiteblood cell counts)
Easybruisingorbleeding(from low blood platelet counts)
Fatigue(from low red blood cell counts and otherreasons)
Diarrhea
Thesesideeffects usuallygo awayaftertreatmentis finished.It's importantto tellyour
health careteam ifyou have anysideeffects, as thereareoften ways to lessen them. For
example, drugs can begiven to help prevent or reducenausea and vomiting.

Otherside effects arealso possible. Someofthese aremore common with certain chemo
drugs. Askyour cancercareteam about thepossibleside effects ofthespecificdrugsyou
aregetting.

Nerve damage (neuropathy)

Manydrugs used to treat breast cancer, includingthetaxanes (docetaxel and paclitaxel),
platinum agents (carboplatin, cisplatin), vinorelbine, eribulin, and ixabepilone, can
damagenerves outsideofthebrain and spinal cord. This can sometimes lead to symptoms
(mainlyin thehands and feet)likenumbness, pain, burningortingling sensations,
sensitivitytocold orheat, orweakness.In most cases this goesawayonce treatment is
stopped, but it might last alongtimein somewomen. (SeePeripheral NeuropathyCaused
ByChemotherapy.)

Hand-foot syndrome
Certain chemo drugs, such as capecitabine and liposomal doxorubicin, can irritatethe
palms ofthehands and thesoles ofthefeet. Thisis called hand-foot syndrome. Early
symptoms includenumbness, tingling,and redness.Ifit gets worse, thehands and feet can
becomeswollen anduncomfortableoreven painful. Theskin mayblister, leadingto
peelingor even open sores. Thereis no specifictreatment, although somecreams may
help. Thesesymptoms graduallyget betterwhen thedrugis stopped orthedoseis lowered.
Thebest waytoprevent severehand-foot syndromeis to tellyourdoctorwhen
earlysymptoms comeup, so that thedrugdose can be changed.

Chemobrain
Anotherpossibleside effect of chemo is "chemo brain."Manywomen whoaretreated for
breast cancer report aslight decreasein mental functioning. Theymayhavesome problems
with concentration and memory,whichmaylast alongtime. Although many women
havelinked this to chemo, it also has beenseen in women who didnot get chemo as part
oftheirtreatment.Still, most women function well aftertreatment.In studies that have found
chemo brain to beasideeffect oftreatment, thesymptoms most often last for a fewyears.
(SeeChemoBrain.)

Feelingunwellor tired (fatigue)

Manywomen do not feel as healthyafterreceivingchemo as theydid before. Thereis often
aresidual feelingofbodypain orachiness and amild loss ofphysical functioning.
Thesemaybeverysubtlechanges that happen slowlyovertime.
Fatigueis another common problem forwomen who have receivedchemo.This maylast up
to severalyears.It canoften behelped, so its important to letyourdoctorornurse know
about it. Exercise, naps, and conservingenergymayberecommended.Ifyou have

sleep problems, theycanbetreated. Sometimes women becomedepressed,which maybe

helped bycounselingand/ormedicines. (SeeFatigue.)

Heart damage
Doxorubicin, epirubicin, and someother chemo drugs maycausepermanent heart
damage(called cardiomyopathy). The risk is highest ifthedrugis used foralongtimeor in
high doses.
Most doctors will checkyourheart function with atest likeaMUGA or an echocardiogram
(an ultrasound oftheheart)beforestartingoneofthesedrugs. Theyalso carefullycontrol
thedoses, watch forsymptoms ofheart problems, and mayrepeat the heart test
duringtreatment.Iftheheart function begins to decline, treatment with these drugs will
bestopped. Still, in somepeople, signsmight not appearuntil months oryears
aftertreatment stops. Heart damagefrom thesedrugs happens moreoften ifotherdrugs that
can causeheart damage, such as drugs that target HER2, areused as well, so doctors
aremore cautious when thesedrugs areused together.

Menstrualchangesand fertilityissues
Foryoungerwomen, changes in menstrual periods areacommon side effect of chemo.
Prematuremenopause (not havinganymoremenstrual periods) and infertility(not being
ableto becomepregnant)mayoccurand maybepermanent. Some chemo drugsaremore
likelyto causethis than others. Theolderawomanis when shegets chemotherapy, the
morelikelyit is that shewill go through menopauseorbecomeinfertileas a result. When this
happens, thereis an increased risk ofboneloss and osteoporosis. Therearemedicines that
can treat orhelp prevent problems with boneloss.
Even ifyourperiods havestopped whileyou areon chemo,you maystill be abletoget
pregnant. Gettingpregnant whileon chemo couldlead to birth defects and interferewith
treatment.Ifyouarepre-menopausal beforetreatment and aresexuallyactive, its important
to discuss usingbirth control withyourdoctor. Forwomen withhormone receptorpositivebreast cancer, sometypes ofhormonal birth control (likebirth control pills) arenot
agood idea,so its important to talkwith bothyouroncologist andyour gynecologist (or
familydoctor) about what options would bebest inyourcase. Women who have finished
treatment (like chemo)can safely go on to havechildren,but it's not safetoget pregnant
whileon treatment.
Ifyou arepregnant whenyouget breast cancer,you still can betreated. Certain chemo
drugscan betaken safelyduringthelast 2 trimesters ofpregnancy. (See Treatment of
breast cancerduringpregnancy.)
Ifyou thinkyou might want to have childrenafterbeingtreatedforbreast cancer, talk
withyourdoctorbeforeyou start treatment. (SeeFertilityandWomenWith Cancer.)

Increased riskof leukemia

Veryrarely, certainchemo drugscan causediseases ofthebonemarrow, such as
myelodysplasticsyndromeor evenacutemyeloid leukemia, alife-threateningcancerof
whiteblood cells. When this happens it is usuallywithin 10years aftertreatment. For most
women, thebenefits of chemo in helpingprevent breast cancer fromcomingback or in
extendinglife arelikelyto far exceed the risk ofthis rarebut serious complication.
Formoreinformation about chemotherapy, seetheChemotherapysection ofourwebsite.

Hormonetherapyfor breast cancer

Sometypes ofbreast cancerareaffected byhormones in theblood. ER-positive and PRpositivebreast cancercells have receptors that attach to estrogen, which helps them grow.
Thereareseveral drugs that usedifferent ways tostop estrogen from attachingto the
receptors.
Hormonetherapyis a form ofsystemictherapy, meaningit reachescancercells anywhere in
thebodyand not just in thebreast.It is recommended forwomen with hormone receptorpositive (ER-positive and/orPR-positive)breast cancers, but it does not help women
whosetumors arehormonereceptor-negative (both ER- and PR-negative).

Whenmighthormonetherapybeused?
Hormonetherapyis most often used aftersurgery(as adjuvant therapy)to help reducethe
risk ofthe cancercoming back, but it can bestarted beforesurgery(as neoadjuvant
treatment) as well.It is usuallyusedfor at least 5 years.
Hormonetherapycanalso beused to treatcancerthat has comeback aftertreatment or that
has spread to otherparts ofthebody.

Howdoeshormonetherapywork?
About 2 out of3 breast cancersarehormonereceptor-positive. Their cellshave receptors
that attach to thehormones estrogen (ER-positive cancers) and/orprogesterone (PRpositive cancers). Forthese cancers, high estrogenlevels help the cancercells grow and
spread.
Thereareseveral differenttypes ofhormonetherapythat usedifferent waysto keep estrogen
from helpingthe cancergrow. Most types ofhormonetherapyforbreast cancer
eitherlowerestrogen levels orstop estrogen from actingon breastcancercells.

Drugsthatblockestrogen
Thesedrugs work bystoppingestrogen from affectingbreast cancer cells.

Tamoxifen
This drugblocksestrogen receptors in breast cancer cells. This stops estrogen from
bindingto the cancercells and tellingthem togrow and divide. Whiletamoxifen acts like an
anti-estrogen in breastcells, it acts like an estrogen in othertissues, liketheuterus and
thebones. Becauseofthis, it is called aselectiveestrogen receptor modulator (SERM).
Tamoxifen can beused in several ways:
Forwomenwith hormone receptor-positivebreastcancertreated with surgery,
tamoxifen can help lowerthe chances ofthecancer comingback andraisethe
chances oflivinglonger.It can also lowerthe riskofgettinganew cancerin theother
breast. Tamoxifen can bestarted eitheraftersurgery(adjuvant therapy)orbefore
surgery(neoadjuvant therapy) and is usuallytaken for5 to 10years. Forearlystage
breast cancer, this drugismainlyused forwomenwho havenotyetgonethrough
menopause. (Ifyou havegonethrough menopause, aromataseinhibitors areusually used
instead.)
Forwomenwho havebeen treatedforductal carcinomain situ (DCIS)thatis hormone
receptor-positive, takingtamoxifen for5 years lowers the chanceofthe
DCIScomingback.It also lowers the chanceofgettingan invasivebreast cancer.
Forwomenwith hormone-positivebreastcancerthat has spreadto otherparts ofthe body,
tamoxifen can often help slow orstop thegrowth ofthe cancer,andmight even shrink
sometumors.
Inwomen at high risk ofbreast cancer, tamoxifen can beused to help lowerthe risk
ofdevelopingbreast cancer.
Toremifene(Fareston)isanotherSERM that works in asimilarway, but it is used less
often and is onlyapproved to treat metastaticbreast cancer.It is not likelyto work if
tamoxifen has alreadybeen used and has stoppedworking.
Thesedrugs aretaken bymouth, most often as apill.
Themost common side effects oftamoxifen and toremifeneare:
Fatigue
Hot flashes
Vaginal dryness ordischarge
Mood swings

Somewomen with cancerspread to thebones mayhavea"tumor flare"with pain and

swellingin themuscles and bones. This usuallysubsides quickly, but in some rare cases a
woman mayalso developahighcalcium level in theblood that is hard to control.Ifthis
happens, thetreatment mayneed to bestoppedforatime.
Rare, but moreserious side effects are also possible:
Thesedrugs can increasethe risk ofdevelopingcancers oftheuterus (endometrial cancer
and uterinesarcoma)in women who havegonethrough menopause. Tellyour doctor
right awayabout anyunusual vaginal bleeding(acommon symptomofboth of these
cancers). Most uterinebleedingis not from cancer, but this symptom always needs
prompt attention.
Blood clots areanotherpossibleserious side effect. Theyusuallyform in thelegs (called
deep vein thrombosis orDVT), but sometimes apieceof clot maybreak off and end up
blockinganarteryin thelungs (pulmonary embolism orPE). Callyour
doctorornurseright awayifyou develop pain, redness, orswellinginyourlowerleg
(calf), shortness ofbreath, or chest pain, becausethese can besymptoms ofaDVT or
PE.
Rarely, tamoxifen has been associatedwith strokes in post-menopausal women, so
tellyourdoctorifyou havesevereheadaches, confusion, ortroublespeakingor moving.
Thesedrugs might also increasethe risk ofaheart attack.
Dependingon awoman'smenopausal status, tamoxifen can havedifferent effects on the
bones.In pre-menopausal women, tamoxifen can causesomebonethinning, but in postmenopausal women it is often good forbonestrength.
Thebenefits oftakingthesedrugs outweigh therisks for almost all women with hormone
receptor-positivebreast cancer.

Fulvestrant (Faslodex )
Fulvestrant is adrugthat blocks estrogen receptorsand also eliminates them temporarily.
This drugis not aSERM it acts like an anti-estrogen throughout thebody.
Fulvestrant is used to treat metastaticbreast cancer, most often afterotherhormonedrugs
(liketamoxifen and oftenan aromataseinhibitor)havestopped working.
It isgiven byinjections into thebuttocks. Forthefirst month, theshots aregiven 2 weeks
apart. Afterthat, theyaregiven onceamonth.
Common short-term side effects can include:
Hot flashes

Night sweats
Mild nausea
Fatigue
Because fulvestrant blocks estrogen, in theoryit could causeweakened bones
(osteoporosis)ifit is taken foralongtime.
Fulvestrant is currentlyapproved onlyforusein post-menopausal women.It is sometimes
used off-labelin pre-menopausal women, often combined with a luteinizing-hormone
releasinghormone(LHRH)agonist to turn offtheovaries (seethe section on
ovarianablation below).

Treatmentstolowerestrogenlevels
Somehormonetreatments work byloweringthe estrogen levels in thebody.Because
estrogen encourages hormone receptor-positivebreast cancers to grow, loweringthe
estrogen levelcan help slow the cancers growth orhelp prevent it from comingback.

Aromatase inhibitors(AIs)
Aromataseinhibitors (AIs) aredrugs that stop estrogen production. Beforemenopause,
most estrogen is madebytheovaries.But forwomen whoseovaries arentworking,
eitherdueto menopauseor certain treatments, asmall amount of estrogenis still madeby an
enzyme(called aromatase)in the fat tissue. AIswork byblockingaromatase from
makingestrogen.
Thesedrugs aremost useful in women who arepast menopause, although theycanalso
beused in premenopausal women if combined with ovarian ablation (seebelow).
TherearethreeAIs that all seem to work about equallywell in treatingbreast cancer:
Letrozole (Femara)
Anastrozole (Arimidex)
Exemestane (Aromasin)
Thesedrugs aretaken dailyas pills.
Usein adjuvant therapy:Aftersurgery, takingan AI, eitheraloneoraftertamoxifen, has been
shown to work betterthan takingjust tamoxifen for5years to reducethe risk ofthe cancer
comingback later.
Schedules that areknown to behelpful include:
Tamoxifen for2 to 3years, followed byan AIto complete5years oftreatment
Tamoxifen for5years, followed byan AIfor5years
An AIforat least 5years

Formost post-menopausal women whosecancersarehormone receptor-positive, most

doctors recommend takingan AIat somepoint duringadjuvant therapy. Right now,
standard treatment is to takethesedrugs forabout 5years (or alternatewith tamoxifen for
atotal of at least 5years). Studies arenow beingdoneto seeiftakingan AI formorethan
5years would bemorehelpful.
Ifyou haveearly-stagebreast cancer and had notgonethrough menopausewhenyou
werefirst diagnosed,yourdoctormight recommend takingtamoxifen first,and then
takingan AIlaterifyougo through menopauseduringtreatment. Anotheroption is
takingadrugcalledaluteinizinghormone-releasinghormone(LHRH)analog, which turns
offtheovaries, alongwith an AI.
Useincancer thatcomes backorhas spread:AIscan also beused to treat more advanced
hormone-positivebreastcancers, especiallyin post-menopausal women. Theyareoften
continued for aslongas theyarehelpful.
Possibleside effects:TheAIs tend to have fewerserious side effects than tamoxifen.
Theydon'tcauseuterinecancers and veryrarelycauseblood clots. Theycan, however,
causemusclepain and joint stiffness and/orpain.Thejoint pain maybesimilarto a
feelingofhaving arthritis in manydifferent jointsat onetime. This side effect may
improvebyswitchingtoadifferent AI, but it has led somewomen to stop treatment.If this
happens, most doctors recommend usingtamoxifen to complete5yearsofhormone
treatment.
BecauseAIs remove all estrogensfrom womenaftermenopause, theyalsocausebone
thinning, sometimes leadingto osteoporosis and even fractures.Ifyou aretaking an AI,
you mayalso begiven medicineto strengthenyourbones, such as bisphosphonates or
denosumab.

Ovarianablation
Forpre-menopausal women, removingorshuttingdown theovaries(ovarian ablation),
which arethemain sourceof estrogens,effectivelymakes them post-menopausal. This
mayallow someotherhormonetherapies, such asAIs, to work better.Ovarian ablation is
most often doneto treatmetastaticbreastcancer,but it can also beused insomewomen with
early-stagedisease.
Thereareseveral ways toremoveorshut down theovaries:
Oophorectomy:Surgeryis doneto removetheovaries. This is a form ofpermanent
ovarian ablation.
Luteinizing hormone-releasing hormone (LHRH)analogs:Thesedrugsareused
moreoften than oophorectomy. Theystop thesignal that thebodysends to ovaries to
make estrogen,which causes temporarymenopause. CommonLHRH drugs include
goserelin (Zoladex) and leuprolide(Lupron).Theycan beused aloneorwith

otherhormonedrugs(tamoxifen, aromataseinhibitors, fulvestrant) as hormone

therapyin pre-menopausal women.
Chemotherapy drugs:Some chemo drugs can damagetheovaries ofpremenopausal women so theyno longermakeestrogen. Forsomewomen, ovarian
function returns months oryears later, but in others, thedamageto theovaries is
permanent and leads tomenopause. This side effect can sometimes beahelpful (if
unintended) consequenceof chemotherapyforbreast cancer.
All ofthesemethods cancausesymptoms ofmenopause, includinghotflashes, night
sweats, vaginal dryness,and mood swings.

Lesscommontypesofhormonetherapy
Someothertypes ofhormonetherapywereusedmoreoften in thepast, but arerarely given
now.Theseinclude:
Megestrol acetate (Megace), aprogesterone-likedrug
Androgens (malehormones)
High doses of estrogen
Thesemight be an optionifother forms ofhormonetherapyareno longerworking, but
theycan oftencausesideeffects.

Targeted therapyfor breast cancer

As researchers havelearned more about changes in cancercells that causethem to grow
out of control, theyvedeveloped new types ofdrugs that target someofthese cell
changes. Thesetargeteddrugsaredesigned to block thegrowth and spreadof cancer cells.
Thesedrugsworkdifferentlyfrom chemotherapydrugs,which attack all cells that
aregrowingquickly(includingcancer cells).
Targeted drugs sometimes work even when chemo drugs do not. Sometargeted drugs can
help othertypes oftreatment work better. Targeted drugs also tend to havedifferent (and
often less severe)sideeffects than chemo.

TargetedtherapyforHER2-positivebreastcancer
For about 1 in 5 womenwith breast cancer, the cancercells havetoo muchofagrowthpromotingprotein knownas HER2/neu (orjust HER2)on theirsurface. These cancers,
known as HER2-positivebreast cancers, tend togrow and spread more aggressively.But
anumberofdrugs havebeen developed that target this protein:

Trastuzumab(Herceptin):This drugis amonoclonal antibody, which is amanmadeversion ofaveryspecificimmunesystem protein.It is oftengiven alongwith
chemo, but it might also beused byitself (especiallyif chemoalonehasalreadybeen
tried). Trastuzumab canbeused to treat both early-and late-stagebreast cancer. When
started beforeoraftersurgeryto treat earlybreast cancer, this drugisusually given
foratotal ofayear. For advanced breast cancer, treatment is oftengiven for as longas
thedrugis helpful. This drugisgiven into avein (IV).
Pertuzumab(Perjeta):This is also amonoclonal antibody. Pertuzumab can begiven
with trastuzumab and chemo, eitherbeforesurgeryto treat early-stagebreast cancer,
orto treat advanced breast cancer. This drugis given into avein (IV).
Ado-trastuzumab emtansine (Kadcyla, also knownasTDM-1):This isa
monoclonal antibodyattached to a chemotherapydrug.It is used byitselfto treat
advanced breast cancerin women who havealreadybeen treated with trastuzumab
and chemo. This drugisalso given into avein (IV).
Lapatinib(Tykerb):This is atypeoftargeted drugknownas akinaseinhibitor.It is taken
dailyas apill.Lapatinib is used to treat advanced breast cancer, most often when
trastuzumab is no longerworking.It is typicallyusedalong with certain chemo
orhormonetherapydrugs.

Side effects of targeted therapyfor HER2-positive breast cancer

Theside effects ofthesedrugsareoften mild, but someserious side effectsarepossible.
Discuss whatyou canexpect withyourdoctor.
Somewomen develop heartdamageduringoraftertreatment with the antibodydrugs
(trastuzumab, pertuzumab, and ado-trastuzumab emtansine). This can leadto congestive
heart failure (wheretheheart doesnt pump bloodas well as it should). Formost (but not
all)women, this effect lasts ashort time and gets betterwhen thedrugis stopped. The
risk ofheart problems is higherwhen thesedrugsaregiven with certainchemo drugs that
also can causeheart damage, such as doxorubicin(Adriamycin)and epirubicin (Ellence).
Becausethesedrugs cancauseheart damage, doctors often checkyourheart function (with
an echocardiogramoraMUGA scan)beforetreatment, andcheck it again every few months
whileyou aretakingthedrug. Majorsymptoms of congestiveheart failure
areshortness ofbreath,leg swelling, and severefatigue.Letyourdoctorknow ifyou
develop anyofthesesymptoms.
Lapatinib can causeseverediarrhea, so its veryimportant to letyourhealth careteam know
about anychangesin bowel habits as soon as theyhappen. This drug can also cause handfootsyndrome, inwhich thehands andfeetbecomesore and red, andmayblister and peel.

Ifyouarepregnant, youshould not take thesedrugs. Theycan harm and even cause death
to the fetus.Ifyoucould becomepregnant, talk toyourdoctor aboutusingeffective birth
control whiletaking thesedrugs.

Targetedtherapyforhormonereceptor-positivebreast
cancer
About 2 out of3 breast cancersarehormonereceptor-positive (ER-positiveorPRpositive). Forwomenwith these cancers, treatment with hormonetherapyis often helpful.
Certain targetedtherapydrugscan makehormonetherapyeven more effective, although
thesetargeted drugscan alsoadd to theside effects.

Palbociclib (Ibrance)
Palbociclib is approved forwomen who havegonethroughmenopauseand have advanced
hormonereceptor-positive, HER2-negativebreast cancer.It is used alongwith a certain
hormonetherapydrugscalled aromataseinhibitors, such as letrozoleor fulvestrant.
Palbociclib blocks proteins in the cell called cyclin-dependent kinase (CDK)4 and
CDK6. Blockingtheseproteins in breast cancercells that arehormonereceptor-positive
helps stop the cells fromdividingto makenewcells. This slows cancergrowth.
Palbociclib is apill that is taken onceadayfor3weeks at atime, with aweek offbefore
startingagain.
Side effects ofpalbociclib tend to bemild and canincludelow red blood cell counts
(anemia), fatigue, nausea, mouth sores, hairloss,and diarrhea. Severelowwhiteblood
cell counts canalso occur, which can increasetherisk ofserious infection.

Everolimus(Afinitor)
Everolimus is approved forwomen who havegonethroughmenopauseand have advanced
hormonereceptor-positive, HER2-negativebreast cancer.It is used alongwith the
aromataseinhibitor exemestane (Aromasin) forwomen whosecancershavegrown
whiletheywerebeingtreated with eitherletrozoleor anastrozole (orifthecancerstarted
growingshortlyaftertreatment with thesedrugs was stopped).
This targeted therapydrugblocks mTOR, aprotein in cells that normallyhelps them
grow and divide. Everolimus mayalso stop tumors from developingnew blood vessels,
which can help limit theirgrowth.In treatingbreast cancer, this drugseems to help
hormonetherapydrugswork better.
Everolimus is apill that is taken onceaday.

Common side effects ofeverolimus includemouth sores, diarrhea, nausea,fatigue,

feelingweak ortired, low blood counts, shortness ofbreath, and cough. Everolimus can
also increaseblood lipids (cholesterol and triglycerides) and blood sugars, soyourdoctor
will checkyourblood work periodicallywhileyouareon this drug.It can also increase
yourrisk ofserious infections, soyourdoctorwillwatchyou closelyforinfection while
youareon treatment.
Everolimus is also being studied foruse forearlierstagebreast cancer, withother
hormonetherapydrugs, and in combination with othertreatments.
Moreinformation aboutmonoclonal antibodies can be found in Cancer Immunotherapy.
Formoreinformation about targeted therapydrugs, seeTargeted Therapy.

Treatment oflobular carcinoma in situ

Lobular carcinomain situ (LCIS)means abnormal cells arein thebreast.LCISis not
cancerorpre-cancer, andit does not usuallyneed to betreated.But having LCISdoes
raiseawomans risk fordevelopingbreastcancer.Forthat reason, ifyou haveLCIS,you
should have regularmammogramsand doctorvisits. Somewomen withLCIStake
medicineto lowertheirrisk ofgettingbreast cancer.
Lobular carcinomain situ (LCIS)is sometimesgrouped with ductal carcinomain situ
(DCIS)as atypeofnon-invasivebreast cancer, but it differs from DCISin that its not a
pre-cancer. That is, it cant become an invasivecancer, even ifit isnt treated.

DoesLCISneedtobetreated?
SinceLCISis not atruecancerorpre-cancer, often no treatment is recommended.
Sometimes ifaneedlebiopsyresult showsLCIS,thedoctormight recommend that it be
removed completely(with an excisional biopsyorsomeothertypeofbreast-conserving
surgery)to help makesurethatLCISwas theonlythingthere.
Having LCISdoes increaseyour risk ofdevelopinginvasivebreast cancerlateron, so close
follow-up is veryimportant. This usuallyincludes ayearlymammogram and a breast exam.
Close follow-up ofboth breasts is important becausewomenwithLCISin onebreast
havethesameincreased risk ofdevelopingcancerin both breasts. Thereisnt
enoughevidenceto recommend gettingroutinemagnetic resonanceimaging(MRI)in
addition to mammograms for all women withLCIS, but its reasonable forwomen with
LCISto talk with theirdoctors about theirotherrisk factors and thebenefits and limits of
beingscreenedyearlywith MRI.
A certain kind ofLCIS, called pleomorphicLCIS,maybemorelikelyto turn into invasive
cancerthan most types ofLCIS. Somedoctors feel that this kind ofLCISneeds to be
removed completelywith surgery.

Canyouloweryourriskofinvasivebreastcancer?
Ifyou haveLCIS,you maywant to considertakingahormonemedicinesuch as tamoxifen or
raloxifene (Evista)to help reduceyour risk ofbreast cancer. (SeeMedicines to
ReduceBreast CancerRisk.)You might also want to considertakingpart in a clinical trial
forbreast cancerprevention, ordiscussingotherpossibleprevention strategies (such as
gettingto ahealthyweight orstartinganexerciseprogram)withyourdoctor.
BecauseLCISis linked to an increased risk ofcancerin both breasts, somewomen with
LCISchooseto haveabilateral simplemastectomy(removal ofboth breasts but not
nearbylymph nodes)to lowerthis risk. This is morelikelyto beareasonableoption for
women who also haveother risk factors forbreast cancer, suchas aBRCAgenemutation
orastrongfamilyhistory. This maybefollowed bydelayed breast reconstruction.

Treatment ofductalcarcinoma in situ

Ductal carcinomain situ (DCIS)means thecells that linethemilk ducts ofthebreast have
changed to look like cancercells underamicroscope, but theyhavenot spread into
surroundingbreast tissue.
Ductal carcinomain situ (DCIS)isconsidered non-invasiveorpre-invasivebreast cancer.
DCIS cant spread outsidethebreast, but it still needs to betreated becauseit can
sometimes go on to becomeinvasivebreast cancer.In most cases,awoman with DCIS can
choosebetween breast-conservingsurgery(BCS) and simplemastectomy.But in some cases
amastectomymight beabetteroption.

Breast-conservingsurgery(BCS)
In breast-conservingsurgery(BCS), thesurgeon removes thetumor and asmall amount
ofnormal breast tissue around it.Lymph noderemoval is not always needed with BCS,
but it maybedoneifthedoctorthinks the areaofDCISmightalso containinvasive cancer.
Therisk of an areaofDCIScontaininginvasive cancergoes up with tumorsize and
nucleargrade.Iflymph nodes areremoved, this is usuallydone as asentinel lymph
nodebiopsy(SLNB).
IfBCSis done, it is usuallyfollowed byradiationtherapy. This lowers thechanceofthe
cancer comingback in thesamebreast (either asmoreDCISor as an invasive cancer).
BCSwithout radiation therapyis not astandard treatment, but it might bean option for
certain womenwho had small areas oflow-gradeDCISthat wereremovedwith large
enoughcancer-freesurgical margins.

Mastectomy
Simplemastectomy(removal ofthe entirebreast)maybeneeded iftheareaofDCISis
verylarge, ifthebreast has several areas ofDCIS,orifBCScannot removetheDCIS
completely(that is, theBCSspecimen and re-excision specimens havecancercells in or
nearthesurgical margins). Manydoctors will do aSLNBalongwith themastectomy. This
is becauseif anareaofinvasive canceris found in thetissue removedduringa
mastectomy, thedoctorwont be abletogo backand do theSLNBlater, and so mayhave to
do a full axillarylymph nodedissection (ALND).
Women havingamastectomyforDCISmaychooseto havebreast reconstruction
immediatelyorlater.

Hormonetherapyaftersurgery
IftheDCISis hormonereceptor-positive (ER-positiveorPR-positive), adjuvant treatment
with tamoxifen (for anywoman)oran aromataseinhibitor (for women past
menopause)for5years aftersurgerycan lowerthe risk of anotherDCISorinvasive
cancerdevelopingin eitherbreast.Ifyou havehormone receptor-positiveDCIS, discuss
thepros and cons ofhormonetherapywithyourdoctors.

Treatment ofinvasivebreast cancer,by

stage
Thestage(extent)ofyourbreast canceris an important factorin makingdecisions about
yourtreatment.Ingeneral, themorethebreast cancerhas spread, themoretreatmentyou will
likelyneed.Butyourtreatment options are affected by yourpersonal preferences and
otherinformation aboutyourbreast cancer, suchas:
Ifthecancer cells contain hormone receptors (that is, ifthe canceris ER-positiveor
PR-positive)
Ifthecancer cells havelarge amounts oftheHER2protein (that is, ifthe canceris
HER2-positive)
Youroverall health
Talk withyourdoctor about how these factors canaffectyourtreatment options.

StageI
Thesebreast cancersarestill relativelysmall andeitherhavenot spread tothelymph
nodes orhaveatinyareaof cancerspread in thesentinel lymph node (thefirst lymph
nodeto which canceris likelyto spread).

Surgery
Surgeryis themain treatment forstageIbreastcancer. Thesecancers canbetreatedwith
eitherbreast-conserving surgery(BCS; sometimes called lumpectomyorpartial
mastectomy)ormastectomy. Thenearbylymph nodes willalso need to bechecked,
eitherwith asentinel lymph nodebiopsy(SLNB)or an axillarylymph nodedissection
(ALND).
In somecases, breast reconstruction can bedoneduringthesurgeryto removethe cancer. But
ifyou will need radiation therapyaftersurgery,it is often betterto wait to get reconstruction
until afterthe radiation is complete.

Radiation therapy
IfBCSis done, radiation therapyis usually given aftersurgeryto lowerthechanceofthe
cancer comingback in thebreast. Women who areat least 70years old mayconsider
BCSwithout radiation therapyifALL ofthe followingaretrue:
Thetumorwas 2 cm (alittleless than 1 inch)orless across and it has beenremoved
completely.
Thetumor contains hormone receptors and hormonetherapyisgiven.
Noneofthelymph nodesremoved contained cancer.
Radiation afterBCSstilllowers the chanceofthecancer comingback in women who
meet thesecriteria, but it has not been shown to help them livelonger.
Somewomen who do not meet thesecriteriamaybetempted to avoid radiation, but studies
haveshown thatnot gettingradiation increases thechances ofthecancer coming back
andcan shorten theirlives.
Ifmastectomyis done, radiation therapyis less likelyto beneeded, but it might begiven
dependingon thedetailsofyourspecific cancer.You should discuss ifyou need radiation
treatment withyourdoctor. Theymaysendyou toadoctorwho specializes in radiation, called
aradiation oncologist, for evaluation.

Adjuvant systemic therapy(chemoandother drugs)

Forwomenwho haveahormone receptor-positive(ER-positiveorPR-positive)breast
cancer, most doctors will recommend hormonetherapy(tamoxifen or an aromatase
inhibitor, orone followed bytheother) asan adjuvant (additional)treatment, no matter
how small thetumoris. Women with tumors largerthan 0.5 cm (about inch) across
maybemorelikelyto benefit from it. Hormonetherapyis typically given for at least 5
years.

Ifthetumoris smallerthan 1 cm (about inch)across, adjuvant chemotherapy(chemo)

is not usuallyneeded. Somedoctors maysuggestchemo ifacancersmallerthan 1 cm has
anyunfavorablefeatures (such as beinghigh-grade, hormonereceptor-negative, HER2positive, orhaving ahighscoreon agenepanel such as OncotypeDx). Adjuvant chemo
is usuallyrecommendedforlargertumors.
ForHER2-positivecancers, ayearof adjuvant trastuzumab (Herceptin)is usually
recommendedas well.
Formoreinformation onadjuvant therapy, seeDrugtreatment forstagesItoIIIbreast
cancer.

StageII
Thesebreast cancersarelargerthan stageI cancers and/orhavespread to afew nearby
lymph nodes.

Localtherapy(surgeryand radiation therapy)

StageIIcancers aretreated with eitherbreast-conservingsurgery(BCS; sometimes called
lumpectomyorpartial mastectomy)ormastectomy.Thenearbylymph nodes will also need to
be checked, eitherwith asentinel lymph nodebiopsy(SLNB)or anaxillary
lymph nodedissection (ALND).
Women who haveBCS aretreated with radiation therapyaftersurgery. Women who
haveamastectomyaretypicallytreated with radiation ifthe canceris found in thelymph
nodes. Somepatients who haveaSLNBthat shows cancerin afew lymph nodes maynot
havetherest oftheirlymph nodes removed(ALND)to checkformore cancer.In these
patients, radiation maybediscussed as atreatment option aftermastectomy.
Ifyou wereinitiallydiagnosed with stageIIbreastcancer and weregiven treatment such as
chemotherapyorhormonetherapybeforesurgery,radiation therapymight be recommended
if canceris found in thelymph nodes at thetimeofthemastectomy.A doctorwho specializes
in radiation, calledaradiation oncologist, mayreviewyour case to discuss
whetherradiation would behelpful toyou.
Ifchemotherapyis also neededaftersurgery, theradiation is delayed until the chemo is
done.
In somecases, breast reconstruction can bedoneduringthesurgeryto removethe cancer. But
ifyou will need radiation aftersurgery, it is often betterto wait to get reconstruction until
afterthe radiation is complete.

Neoadjuvantand adjuvant systemic therapy(chemo andother drugs)

Systemictherapyis recommended forwomenwith stageIIbreast cancer.Somesystemic
therapies aregiven beforesurgery(neoadjuvant therapy),and othersaregiven after
surgery(adjuvant therapy).Neoadjuvant treatments areoftenagood option forwomen with
largetumors, becausetheycan shrink thetumorbeforesurgery, possiblyenough to
makeBCSan option. But this doesnt improvesurvival morethangettingthedrugs after
surgery.In somecases, systemictherapywill bestarted beforesurgeryandthen continued
aftersurgery.
Thedrugs used will depend on thewomans ageand thetumors hormone-receptorstatus
and HER2 status. Theymayinclude:
Chemotherapy:Chemocan begiven beforeoraftersurgery.
HER2 targeted drugs:Ifthe canceris HER2-positive, HER2 targeted drugs are
started alongwith chemo. Both trastuzumab (Herceptin) and pertuzumab (Perjeta)
maybeused asapart ofneoadjuvant treatment. Then trastuzumab is continued after
surgeryforatotal ofoneyearoftreatment.
Hormone therapy:Ifthe canceris hormonereceptor-positive, hormonetherapy
(tamoxifen, an aromataseinhibitor, orone followed bytheother)is typicallyused.It can
bestarted beforesurgery, but becauseit continues for at least 5years, it needs to
begiven aftersurgeryaswell.
Formoreinformation onadjuvant and neoadjuvant therapy, seeDrugtreatment for
stagesItoIIIbreastcancer.

StageIII
In stageIIIbreast cancer,thetumoris large (morethan 5 cm or about 2 inches across)or
growinginto nearbytissues (theskin overthebreast orthemuscleunderneath), orthe
cancerhas spread to manynearbylymph nodes.
Ifyouhaveinflammatory breast cancer:StageIIIcancers also includesome
inflammatorybreastcancers that havenot spread beyond nearbylymph nodes. Treatment
ofthesecancers can beslightlydifferent from thetreatment ofotherstageIIIbreast cancers.
SeeInflammatoryBreast Cancer fordetails.
Therearetwo mainapproaches to treatingstageIIIbreast cancer:

Startingwith neoadjuvant therapy

Most often, these cancersaretreated with neoadjuvant chemotherapy(beforesurgery).
ForHER2-positivetumors, thetargeted drugtrastuzumab (Herceptin)is given as well,
sometimes alongwith pertuzumab (Perjeta). Thismayshrink thetumorenough to allow a

woman to havebreast-conservingsurgery(BCS).Ifthetumordoesnt shrink enough,a

mastectomyis done.Nearbylymph nodes will also need to be checked. Asentinel lymph
nodebiopsy(SLNB)is often not an option forstageIII cancers, so anaxillarylymph
nodedissection (ALND)is usuallydone.
Often, radiation therapyis needed aftersurgery.Ifbreast reconstruction is done, it is
usuallydelayed until after radiation is complete.In some cases,additional (adjuvant)
chemo is givenaftersurgeryas well. Women with HER2-positive cancers receive
trastuzumab aftersurgeryto completeayearoftreatment. Women with hormone receptorpositive (ER-positiveorPR-positive)breast cancers will get adjuvant hormone therapy.

Startingwith surgery
Anotheroption forstageIIIcancers is to treat with surgeryfirst.Becausethesetumors
arefairlylarge and/orhavegrown into nearbytissues, this usuallymeansgettinga
mastectomy.Forwomenwith fairlylargebreasts,BCSmaybe an option ifthe cancer
hasnt grown into nearbytissues. SLNBmaybean option forsomepatients, but most will
need an ALND. Surgeryis usuallyfollowed byadjuvant systemicchemotherapy,
and/orhormonetherapy,and/ortrastuzumab. Radiation is recommendedaftersurgery.
Formoreinformation onadjuvant and neoadjuvant therapy, seeDrugtreatment for
stagesItoIIIbreastcancer.

DrugtreatmentforstagesI toIIIbreastcancer
Most women with breastcancerin stagesItoIIIwill get somekind ofdrug therapyas part
oftheirtreatment. This mayinclude:
Chemotherapy
Hormonetherapy(tamoxifen, an aromataseinhibitor, orone followed bytheother)
HER2 targeted drugs, such as trastuzumab (Herceptin) and pertuzumab (Perjeta)
Some combination ofthese
Thetypes ofdrugs thatmight work best dependon thetumors hormonereceptorstatus,
HER2 status, and otherfactors.

When ischemotherapy(chemo) used?

Chemo is usuallyrecommended forall women with an invasivebreast cancerwhose
tumoris hormone receptor-negative(ER-negativeand PR-negative).Itsalso typically
recommendedforwomen with hormone receptor-positivetumors who might benefit from

gettingchemo alongwith theirhormonetherapy, based on thestageand characteristics of

theirtumor.
Chemo, given eitherbeforesurgery(neoadjuvant chemo)or aftersurgery(adjuvant
chemo), can lowerthe risk ofthe cancercomingback, but it doesnt removethe risk
entirely.Beforedeciding ifits right foryou, talk toyourdoctorto makesureyou
understand the chanceofyourcancerreturningboth with orwithout getting chemo.
Ifyou will begetting chemo,yourdoctorshould discuss what specificdrug regimens are
best foryou based onyour cancer, its stage,yourotherhealth issues, andyour preferences.
Thelength oftreatment usuallyranges from 3 to 6 months.

When ishormone therapyused?

Hormonetherapyis recommended for all womenwith hormone receptor-positive (ERpositiveorPR-positive)invasivebreast cancer, regardless ofthesizeofthetumororthe
numberoflymph nodeswith cancer cells. Hormonetherapyis not likelyto be effective
forwomen with hormonereceptor-negativetumors.
Forpost-menopausal women:Women who havegonethrough menopause and who
havehormonereceptor-positivetumors will generally getadjuvant hormonetherapy.
This might consist of:
An aromataseinhibitor, such as anastrozole(Arimidex), letrozole (Femara),or
exemestane (Aromasin) for5years
Tamoxifen for2 to 5years followed byanaromataseinhibitor for3 to 5 moreyears
Tamoxifen for5 to 10years (forwomen whocan'ttake aromataseinhibitors)
Chemotherapycan sometimes slow orstop ovarian function foratime. Women who
stopped havingperiods duringorafter chemo mayneed theirhormonelevels tested to
check to seeiftheyaretrulyin menopause. Manywomen whoseperiods stopped from
chemo havenot truly gonethroughmenopause,and theirperiods will return.
Forpre-menopausal women:Forwomen who havent gonethrough menopause, the most
common treatment is tamoxifen, which is taken for5 to 10years. Aromatase inhibitors
dont help iftheovariesarestill making estrogen, so theyarenotusually given to premenopausal women.
Somedoctors also giveadrug called aluteinizing hormone-releasinghormone(LHRH)
analog, which temporarilystops theovaries from functioning. Another(permanent)
option is surgical removal oftheovaries (oophorectomy). Still, its not clearthat
removingtheovaries orstoppingthem from workinghelps tamoxifen workbetter for
cancers that havebeenremoved completely, so thesetreatments arenot standard.

Ifyougo through menopauseduringtamoxifen treatment (eithernaturallyorbecause

yourovaries areremoved),you maybeswitchedfrom tamoxifen to an aromatase inhibitor.
Still, women maystop havingperiods on tamoxifen without trulygoingthrough menopause,
so blood tests ofhormonelevels areoften needed to seeifyouarein menopause andcan
benefit from aromataseinhibitors. Women who had theiruterus removed
(ahysterectomy)but still havetheirovaries mayneed to haveblood tests to check
hormonelevels toseeiftheyhavegonethrough menopausebeforetaking an
aromataseinhibitor.
Anotheroption forpre-menopausal women(instead oftamoxifen), is taking anLHRH
analogto turn offtheovaries alongwith an aromataseinhibitor.
Hormone therapy andchemotherapy:Hormonetherapymight bestartedright awayif you
arenotgettingchemo. Butgettinghormonetherapyandchemo together can make the chemo
less effective,so hormonetherapyis usuallynot started until after chemo is completed.

When are HER2targeted drugsused?

Women who haveHER2-positive cancers areusually given trastuzumab (Herceptin)
alongwith chemo as part oftheirtreatment.Ifthetreatment is given beforesurgery (called
neoadjuvant therapy), pertuzumab (Perjeta)maybegiven aswell.After chemo is finished,
thetrastuzumab is continued to completeayearoftreatment.
Becausethesedrugs canlead to heart problems, heart function is watchedcloselyduring
treatment with tests suchas echocardiograms orMUGA scans.

Online toolstohelpmake decisions

To help decideifadjuvant therapyis rightforyou,you might want to visit theMayo
Clinicwebsite at www.mayoclinic.com and type"adjuvant therapyforbreast cancer"into
thesearch box. You willfind apagethat will helpyou to understand thepossiblebenefits and
limits of adjuvant therapy.
Otheronlineguides, suchas www.adjuvantonline.com, aredesigned to beused byhealth
careprofessionals. Thiswebsitehas informationaboutyour risk ofthecancerreturning within
thenext 10yearsand what benefitsyou might expect from hormonetherapy and/or
chemotherapy. You maywant to askyourdoctorifheorsheuses this site.

StageIV
StageIVcancers havespread beyond thebreast and nearbylymph nodes tootherparts of
thebody. When breast cancerspreads, it most commonly goes to thebones,liver, and
lungs. As thecancerprogresses, it mayalso spreadto thebrain orotherorgans.

Forwomenwith stageIVbreast cancer, systemic(drug)therapies arethemain

treatments. Thesemayinclude:
Hormonetherapy
Chemotherapy(chemo)
Targeted drugs, such as trastuzumab (Herceptin)and pertuzumab (Perjeta)
Some combination ofthese
Less often, surgeryand/or radiation therapymaybeuseful in certain situations (see
below).
Treatment can often shrink tumors (orslow theirgrowth), improvesymptoms, and help
women livelonger.But in general, thesecancers areveryhard to cure.

Systemic (drug) treatmentsfor stage IVbreast cancer

Thetypes ofdrugs used forstageIV breastcancerdepend on thehormonereceptorstatus and
theHER2 status ofthe cancer:
Hormone receptor-positive cancers:Women with hormone receptor-positive (ERpositiveorPR-positive) cancers areoften treatedfirst with hormonetherapy (tamoxifen
or an aromataseinhibitor). Women who arepost-menopausal areoften treated first
with anaromataseinhibitor. This maybe combined with atargeted drug such as
palbociclib (Ibrance)oreverolimus (Afinitor). Women who haventyetgone through
menopauseareoften treated first with tamoxifen. But becausehormone therapycan
takemonthsto work, chemo is often the first treatment forpatients with serious
problems from their cancerspread, such asproblems breathing.
Hormone receptor-negative cancers:Chemo is themain treatment for women with
hormone receptor-negative (ER-negative and PR-negative)cancers, becausehormone
therapyisnt helpful forthese cancers.
HER2-positive cancers:Trastuzumab (Herceptin)mayhelp women withHER2positive cancers livelongerifitsgiven alongwithchemo. Pertuzumab (Perjeta),
anothertargeted drug, might beadded aswell. Anotheroption is thetargeted drug
ado-trastuzumab emtansine (Kadcyla), which is given alone.
Treatment oftencontinues until the cancerstarts growing again oruntil side effects
becomeunacceptable.Ifthis happens, otherdrugsmight betried.

Localor regionaltreatmentsfor stage IVbreast cancer

Although systemicdrugsarethemain treatment forstageIV breastcancer,local and
regional treatments suchas surgery,radiation therapy, or regional chemotherapyare

sometimes used as well.Thesecan help treat breast cancerin aspecificpart ofthebody, but
theyareveryunlikelytoget rid ofall ofthecancer.Thesetreatments aremorelikely to beused
to help prevent ortreat symptoms orcomplications from the cancer.
Radiation therapyand/orsurgerymayalsobeusedin certain situations, such as:
When thebreast tumoris causing an openwound in thebreast (or chest)
To treat asmall numberofmetastases in acertainarea, such as thebrain
To help prevent bone fractures
When an areaofcancerspread is pressingon thespinal cord
To treat ablood vessel blockagein theliver
To provide reliefofpainorothersymptoms
In somecases,regional chemo (wheredrugs aredelivered directlyinto acertain area,
such as into the fluid around thebrain orinto theliver)maybeuseful as well.
Ifyourdoctorrecommends such local orregionaltreatments, it is important thatyou
understand theirgoalwhetherit is to tryto curethe cancerorto prevent ortreat
symptoms.

Relievingsymptomsofadvancedbreastcancer
Treatment to relievesymptoms (palliativetreatment)depends on wherethecancerhas
spread.For example, pain from bonemetastases maybetreated with radiation therapy
and/ordrugs called bisphosphonates such as pamidronate (Aredia)orzoledronic acid
(Zometa). Most doctors recommend bisphosphonates orthedrugdenosumab (Xgeva),
alongwith calcium and vitamin D, for all patients whosebreast cancerhasspread to their
bones. Formoreinformation about treatment ofbonemetastases, seeBoneMetastasis.

Advancedcancerthatprogressesduringtreatment
Treatment for advancedbreast cancer can often shrink the cancerorslow its growth
(often formany years), but afteratime, it tends tostop working.Furthertreatment options
at this point depend on severalfactors, includingprevious treatments, wherethe canceris
located,and awoman'sage,general health, and desireto continuegetting treatment.

Progressionwhileon hormone therapy

Forhormonereceptor-positive (ER-positiveorPR-positive) cancers that werebeing
treated with hormonetherapy, switchingto anothertypeofhormonetherapysometimes

helps. For example, if eitherletrozole (Femara)oranastrozole (Arimidex)weregiven,

usingeverolimus (Afinitor)with exemestanemaybe an option.Ifthecanceris no longer
respondingtoanyhormonedrugs, chemotherapyis usuallythenext step.

Progressionwhileon chemotherapy
Ifthecanceris no longerrespondingto one chemoregimen, tryinganothermaybe
helpful. Manydifferent drugsand combinations can beused to treat breast cancer.
However, each timeacancerprogresses duringtreatment, it becomes lesslikelythat
furthertreatment will have an effect.

ProgressionwhilegettingHER2drugs
HER2-positive cancers that no longer respond totrastuzumab (Herceptin)might respond
to lapatinib (Tykerb),anotherdrugthat attacks theHER2 protein. This drugis often
givenalong with the chemo drug capecitabine (Xeloda), but it can beusedwith other
chemo drugs, with trastuzumab, or even alone(without chemo). Otheroptions forwomen
with HER2-positive cancers includepertuzumab (Perjeta)with chemo andtrastuzumab,
or ado-trastuzumab emtansine (Kadcyla).
Becausecurrent treatments areveryunlikelyto cure advanced breast cancer, ifyouarein
otherwisegood health,you maywant to think about takingpart in aclinical trial testinga
newerpromisingtreatment.

Recurrentbreastcancer
Forsomewomen, breast cancermaycomebackaftertreatment sometimesyears later. This
is called arecurrence. Recurrence can belocal (in thesamebreast orin the
mastectomyscar), regional (in nearbylymph nodes), orin adistant area. Cancerthat is
found in theoppositebreast is not a recurrenceit is anew cancerthat requires its own
treatment.

Treatinglocalrecurrence
Forwomenwhosebreastcancerhas recurred locally, treatment depends ontheirinitial
treatment.Ifyou had breast-conservingsurgery,alocal recurrencein thebreast is usually
treated with mastectomy.Iftheinitial treatment was mastectomy, recurrencenearthe
mastectomysiteis treated byremovingthetumorwheneverpossible. This is followed by
radiation therapy, but onlyifnonehad beengivenaftertheoriginal surgery.(Radiation
usuallycant begiven tothesame areatwice.)Ineither case, hormonetherapy, targeted
therapy(liketrastuzumab), chemotherapy, orsomecombination ofthesemaybeused
aftersurgeryand/or radiation therapy.

Treatingregionalrecurrence
When breast cancercomes back in nearbylymphnodes (such as thoseunderthearm or
around the collarbone), it is treated byremovingthoselymph nodes. Thismaybe followed
byradiation aimed at the area. Systemictreatment (such as chemo, targeted therapy,
orhormonetherapy)maybeconsideredafterthelocal treatment aswell.

Treatingdistant recurrence
Ingeneral, women whosebreastcancer comes back in otherorgans, such as thebones,
lungs, orbrain, aretreated thesamewayas thosefound to havestageIVbreast cancerin
theseorgans when theywerefirst diagnosed (seetreatment forstageIV).Theonly
differenceis that treatment maybeaffected byprevious treatments awoman has had.
Recurrent breast cancercan sometimes behard totreat.Ifyouarein otherwisegood
health,you maywant to think about takingpart in a clinical trial testing anewer
promisingtreatment.
SeetheUnderstandingRecurrencesection formoreinformation.

Treatment ofbreast cancer during pregnancy

Breast canceris diagnosed in about 1 pregnant woman out of3,000.Ingeneral, treatment
recommendations depend upon how longthewoman has been pregnant.
Radiation therapyduring pregnancyis known to increasethe risk ofbirth defects, so it is
not recommendedforpregnant women with breastcancer. Sincebreast-conserving
surgery(BCS)needs to be followed with radiation, BCSis onlyan option ifradiation can
bedelayed until afterthebabyis delivered.But breast biopsyprocedures and even
mastectomyand lymph node removal can bedonesafelyin pregnancy.
Foralongtimeit was assumed that chemotherapy(chemo)was dangerous to the fetus. But
several studies havefound that usingcertain chemo drugs duringthesecond and third
trimesters (the fourth to ninth months)does not increasethe risk ofbirth defects. Because of
concern about thepotential damageto the fetus,thesafetyofchemo duringthe first trimester
(the first 3 months)ofpregnancyhas notbeen studied.
Both hormonetherapyand targeted therapycan affect the fetusand should not bestarted
until afterthebabyis born.
Manychemo and hormonetherapydrugs canenterbreast milk and could bepassed on to
thebaby, so breastfeedingis not usuallyrecommended duringchemo, hormone, or targeted
therapy.
Ifyoud likemoreinformation on adrugused inyourtreatment, call us with thenames of
themedicinesyouretaking.

Formoreinformation, seePregnancyand BreastCancer.

What should you askyour cancer care team

about breastcancer?
Thedoctors, nurses, andothermembers ofyourcancercareteam arethebest sourceof
information aboutyourcancer.Theywill explain yourdiagnosis, treatmentoptions, and
progress.But not all women want thesameamount ofinformation orhavethesame
questions. You can takean active roleinyourcarebylearningaboutyourcancer and its
treatment and byasking questions.
Herearesomequestions thatyou can useto helpyou betterunderstandyour cancerand
yourtreatment options. Dont be afraid to takenotes and tell thedoctorsornurses when
you dont understand what theyresaying.You might want to bringanotherperson with
you whenyou seeyourdoctors, and/or ask ifitsOK to recordyour conversation to help
you rememberwhat wassaid.
Not all ofthesequestionswill applytoyou, but theyshould help getyou started.

Whenyouretoldyouhavebreastcancer
Exactlywhat typeofbreast cancerdoIhave?
How bigis thecancer? Where exactlyis it?
Has the cancerspread to mylymph nodes orotherorgans?
Whats thestageofthecancer?What does that mean?
Will Ineed anyothertests beforewecan decideon treatment?
DoIneed to see anyotherdoctors orhealth professionals?
What is thehormone receptorstatus ofmycancer? What does this mean?
What is theHER2 statusofmycancer?What doesthis mean?
How do thesefactors affect mytreatment options and long-term outlook (prognosis)?
What aremychances ofsurvival, based on mycancer asyou seeit?
ShouldIthink aboutgenetictesting?What wouldthepros and cons oftestingbe? How
doIget acopyofmypathologyreport?

IfIm concerned about the costs and insurance coverageformydiagnosis and

treatment, who can helpme?

Whendecidingonatreatmentplan
How much experiencedoyou havetreatingthis typeof cancer?
ShouldIget asecond opinion?How doIdo that?
What aremytreatment choices?
What treatment doyourecommend and why?
ShouldIthink about takingpart in a clinical trial?
What would thegoal ofthetreatment be?
How soon doIneed to start treatment?
How longwill treatment last?What will it belike? Wherewill it bedone?
Will anyofthetreatment bedonebyotherdoctors?
What shouldIdo to get readyfortreatment?
What risks and side effects shouldIexpect?
What canIdo to reducetheside effects ofthetreatment?
ShouldIchangewhatIeat ormakeotherlifestylechanges? How
will treatment affect mydailyactivities?
Will Ibeableto work duringtreatment?
Will Ilosemyhair?Ifso, what canIdo about it?
Will Igo through menopause as aresult ofthetreatment? WillIbe ableto have
children aftertreatment? Would Ibe ableto breastfeed?
What arethe chances thecancerwill comeback afterthis treatment?
What would wedo ifthetreatment doesnt work orifthe cancercomes back?

Ifyouneedsurgery
Is breast-conservingsurgery(lumpectomy)an option forme?Whyorwhynot?
What arethepros andcons ofbreast-conservingsurgeryversus mastectomy?

How manysurgeries likeminehaveyou done?

Willyou haveto takeout lymph nodes?Ifso, wouldyou adviseasentinel lymph
nodebiopsy?Whyorwhynot?
What side effects might lymph noderemoval cause?
Will Ineed blood transfusions?
How longwillIbein thehospital?
Will Ihavestitches orstaples at thesurgerysite?Will therebeadrain (tube) coming out
ofthesite?
How doIcareforthesurgerysite? Will Ineed someoneto help me?
What will mybreasts look and feel likeaftermytreatment? Will Ihavenormal
feelingin them?
What will thescarlook like?
Is breast reconstruction surgeryan option ifIwant it? What would it involvein my
case?
CanIhavereconstruction at thesametime as thesurgeryto removethecancer?What
arethepros and cons ofhavingit done right awayorwaitinguntil later?
What types ofreconstruction might beoptions forme?
ShouldIspeakwith aplasticsurgeon about reconstruction options?
Will Ineed abreast form (prosthesis), and ifso, wherecanIget one?
DoIneed to stop taking anymedications orsupplements beforesurgery?
When willIneed toreturn fora follow-up visit?
When shouldIcallyourofficeifIm havingsideeffects?

Duringtreatment
Oncetreatment begins,youll need to know whatto expect and what to look for. Not all
ofthesequestions mayapplytoyou, but askingtheones that do maybehelpful.
How will weknow ifthetreatment is working?
Is there anything I can doto help managesideeffects?
What symptoms orside effects shouldItellyou about right away?

How canIreachyou onnights, holidays, orweekends?

DoIneed to changewhatIeat duringtreatment?
Arethere anylimits on whatIcan do?
What kind of exerciseshouldIdo,and how often?
Canyou suggestamental health professionalI can seeifIstart to feel overwhelmed,
depressed, ordistressed?
Will Ineed special tests, such as imagingscans orblood tests?How often?

Aftertreatment
DoIneedaspecial diet aftertreatment?
Arethere anylimits on whatIcan do?
AmIat risk forlymphedema?
What canIdo to reducemyrisk forlymphedema?
What shouldIdo ifInoticeswelling?
What othersymptoms shouldIwatch for?
What kind of exerciseshouldIdo now?
What typeof follow-upwillIneed aftertreatment?
How often willIneed to have follow-upexams and imagingtests?
Will Ineed anyblood tests?
How will weknow ifthecancerhascomeback? What shouldIwatchfor?
What would myoptionsbeifthe cancer comes back?

Otherquestions
Besureto writedownanyotherquestionsyou think of. Forinstance,youmight want
specificinformation about recoverytimes so that you can planyourwork schedule. Or you
maywant to ask about nearbyoronlinesupport groupswhereyou can talk with other women
goingthrough similarsituations.

Living as a breast cancersurvivor

Formanywomen with breast cancer, treatment mayremoveordestroythecancer.The end
oftreatment can beboth stressful and exciting. Youll be relieved to finish treatment, yet
its hard not to worryabout cancer comingback. This is verycommon amongpeople who
havehadcancer.
Forotherwomen, breastcancermaynevergoawaycompletely. Somewomen may get
regulartreatments with chemotherapy, radiation therapy, orothertreatments to tryto help
keep thecancerin check.Learningto livewith cancerthat does notgoawaycan be difficult
and verystressful.Living with cancerisdifferentfrom livingafter cancer.
Life afterbreast cancermeans returningto somefamiliarthings andalsomakingsome new
choices.

Follow-upcareafterbreastcancertreatment
Even afteryou havecompleted breastcancertreatment,yourdoctors will want to watch you
closely.Its veryimportant to go to all ofyour follow-up appointments. Duringthese
visits,yourdoctors will ask ifyou arehaving anyproblems and maydo exams and lab tests
orimagingtests to look forsigns of cancerortreatment sideeffects.
Almost anycancertreatment can haveside effects. Somemight onlylast fora few days
orweeks, but others might last alongtime. Someside effects might not even show up
untilyearsafteryou havefinished treatment. Visits withyourdoctor areagood time for you
to ask questions and talk about anychanges orproblemsyou noticeorconcernsyou have.

Typicalfollow-up schedulesafter breastcancer

Doctorvisits:At first,your follow-up doctorvisits will probablybescheduled for
everyfew months. Thelongeryou havebeenfreeof cancer, theless oftenthe
appointments areneeded.After5years, theyaretypicallydone about onceayear.
Mammograms:Ifyou had breast-conservingsurgery,you will get amammogram about
6 months aftersurgeryand radiation are completed, and then at least every year
afterthat.Ifyou hadamastectomy youwill still need to haveyearlymammograms
on the remainingbreast.
Pelvicexams:Ifyou aretakingeitherofthehormonedrugs tamoxifen ortoremifene, you
should havepelvicexams every yearbecausethesedrugs can increaseyourrisk
ofuterinecancer. This risk is highest in women who havegonethrough menopause.
Besureto tellyourdoctor rightawayabout anyunusual vaginal bleeding,such as vaginal
bleedingorspottingaftermenopause, bleedingorspottingbetweenperiods,

ora changeinyourperiods. Although this is usuallycaused bysomethingthat isnt

cancer, it canalso bethefirst sign ofuterinecancer.
Bonedensity tests:Ifyou aretakinganaromataseinhibitor (anastrozole, letrozole, or
exemestane) forearly-stagebreastcancer,yourdoctorwill want to monitoryourbone
health and mayconsidertestingyourbonedensity.
Other tests:Othertests such as blood tests and imagingtests (likebonescans and chest
x-rays) arenot astandard part offollow-up becausetheyhavent beenshown to help
awoman treated forbreast cancerlivelonger. But theymight bedoneifyou
havesymptoms orphysical exam findings that suggest that thecancermight have
comeback(recurrence).These and othertests mayalso bedone as part ofevaluating new
treatments byclinical trials.
Ifsymptoms, exams, ortests suggest apossiblerecurrenceofyourcancer,imagingtests such
as an x-ray, CT scan, PET scan, MRIscan, bonescan, and/orabiopsymaybedone.
Yourdoctormayalso look for circulatingtumorcells in theblood ormeasurelevels of blood
tumormarkers such as CA-15-3, CA 27-29,orCEA. Theblood levels oftumor markersgo
up in somewomen iftheir cancerhasspread to bones orotherorgans such as theliver.
Theyarenot elevated in all women withrecurrence, so theyaren't always
helpful.Iftheyareelevated,yourdoctormight usethem to monitorthe results oftherapy.

Keepinghealthinsuranceandcopiesofyourmedical
records
Even aftertreatment, its veryimportant to keep health insurance. Tests and doctorvisits
cost alot, and even though no onewants to think oftheir cancercomingback, this could
happen.
At somepoint afteryourcancertreatment,you might findyourselfseeinganew doctor who
doesnt know aboutyourmedical history.Itsimportant to keep copiesofyour medical
records togiveyournew doctorthedetails ofyourdiagnosis and treatment. Learn morein
Keeping Copies of Important Medical Records.

Managinglong-termsideeffects
Most side effects goawayaftertreatment ends, but somemaycontinueandneed special
careto manage. Someoftheside effects morelikelyto occur afterbreast cancer treatment
include:
Lymphedema
Post-mastectomypain syndrome
Chemo brain

If thecancercomesback(recurs)
Ifcancerdoes recur,yourtreatment options will depend on thelocation ofthe cancerand
what treatmentsyou'vehad before. Options mightincludesurgery,radiation therapy,
hormonetherapy,chemotherapy, targeted therapy,orsome combination ofthese. For
moreinformation on how recurrent canceris treated, see Treatment ofbreast cancer, by
stage.Formoregeneralinformation on dealingwith a recurrence, seetheUnderstanding
Recurrencesection ofourwebsite.

Emotionalaspects of breast cancer

Some amount ofdepression, anxiety,and fearis normal when breast canceris apart of
yourlife. Somepeopleare affected morethan others. But everyonecan benefit from help
and support from otherpeople, whether friendsand family, religiousgroups, support
groups, professional counselors, orothers.
Youll probablybe concerned that thecancermight comeback,andyou might find
yourselfthinkingabout death and dying. Maybeyouremoreawareoftheeffects the
cancerhas had onyourfamily, friends, and career. You maytakeanew look atyour
relationships with those aroundyou.Unexpected issues might also cause concern.For
instance,you might bestressed byfinancial concerns resulting fromyourtreatment. You
might also seeyourhealth careteam less oftenaftertreatment and havemoretimeon
yourhands. Anyofthesethings might makeyouanxious.

Specialissueswomenwithbreastcancerface
Manywomen with breast cancerfaceadditional stressful issues. Forexample,you might
have changes inyour appearanceas aresult ofbreast cancersurgery. Youmayalso have
concernsabout sexualityafterbreast cancer. Formoreon thesetopics, seeBodyimage and
sexualityafterbreast cancer.
Foryoungerbreast cancersurvivors, changes in appearanceand sexualitymight be even
morestressful. Somewomen might still bethinkingabout having a family, and might
worryabout how thecancer and its treatment might affect this. Others might have already
started families and might worryabout how this could affect them. Forsomewomen,
chemotherapymaycauseearlymenopause, whichcan beverydistressingon its own.
Regardless ofthechangesyou mayexperience, it's important to know that thereis advice
and support out theretohelpyoucope.

Findinghelpandsupport
Almost everyonewho isgoingthrough orhas been throughcancercan benefit from some
typeofsupport. You need peopleyou can turn toforstrength andcomfort.Support can

comein manyforms: family,friends, cancersupport groups,religious orspiritual groups,

onlinesupport communities, orone-on-one counselors. Whats best foryou depends on
yoursituation and personality. Somepeoplefeel safein peer-supportgroups or education
groups. Others would rathertalk in an informal setting, such as church. Others mayfeel
more at easetalkingone-on-onewith atrusted friend or counselor. Whateveryoursource
ofstrength or comfort, makesureyou haveaplaceto go withyourconcerns.
Therearemanysupport groupsavailable, suchastheAmerican CancerSocietyReach To
Recoveryprogram. Thisprogram matchesyou upwith alocal volunteerwho has had breast
cancer. As someonewhos been through theexperience,yourReachTo Recovery volunteer
cananswermanyofyourquestions.
The cancerjourneycan feel verylonely. You shouldnt feel theneed to tryto deal with
everythingonyourown,andyour friends and familymayfeel shut out ifyou dont
includethem.Let them in, and let in anyone elsewhoyoufeel mayhelp.
Ifyou arent surewho can help, callyourAmerican CancerSocietyat 1-800-227-2345
and wecan putyou in touch with agroup orresourcethat maywork foryou.

Bodyimage and sexualityafter breast cancer

Feelinggoodabout yourbodyduringandafterbreastcancer
treatment
Alongwith the emotional stress that cancer and its treatment cancause, manywomen
with breast canceralso find themselves copingwith changes in theirappearanceas a
result oftheirtreatment.
Some changes maybeshort term, such as hairloss. But even short-term changescan
haveaprofound effect on how awoman feels about herself. A numberofoptions are
availableto helpyou copewith hairloss, includingwigs, hats, scarves,andother accessories.
Alternatively,somewomen chooseto usetheirbaldness asawayto identify themselves as
breast cancersurvivors.
Other changes aremorepermanent, likethelossofpart or all ofabreast (orbreasts)after
surgery. Somewomenchooseto havereconstructivesurgeryto rebuild thebreast mound.
Ifyou decidenot to havebreast reconstruction,youcan decidewhethertowearabreast form
orprosthesis ornot.

Sexualityafterbreastcancer
You mayhaveconcernsabout sexualityafterbreast cancer. Physical changes, especially
afterbreast surgery, canmakesomewomen less comfortablewith theirbodies. There
maybealoss ofsensation in the affected breast.Othertreatments forbreast cancer, such

as chemotherapy, can changeyourhormonelevels and mayaffectyoursexual interest

and/or response.
Relationship issues are also important. Yourpartnermayworryabout howto express
lovephysicallyand emotionallyaftertreatment, especiallyaftersurgery. But breast
cancercan beagrowth experience forcouples especiallywhen partners takepart in
decision-makingandgoalongto treatments.
To learn more, seeSexualityfor theWoman with Cancer.

Findinghelpandsupport
Regardless ofthechangesyou mayexperience, it's important to know that thereis advice
and support out theretohelpyoucopewith them.Speakingwithyourdoctororother members
ofyourhealth careteam is often agood startingpoint. Thereare also many support
groupsavailable,such as theAmerican CancerSocietyReach To Recovery program. This
program matchesyou up with alocal volunteerwho has had breastcancer. YourReach To
Recoveryvolunteer cananswermanyofyourquestions.She cangive
you suggestions, additional readingmaterial, and advice. Rememberthat she's been there
and will probablyunderstand.
Somestudies suggest thatyoungerwomen, who representabout 1 out of4 breast cancer
survivors, tend to havemoreproblems adjustingto thestresses ofbreast cancer and its
treatment.It canfeel sociallyisolating.Younger women mayalso bemoreaffected by
issues ofsexualityor fertility.Ifyou arehavingtrouble adjustingafterabreast cancer
diagnosis, look fora counselororasupportgroupdirected atyoungerbreast cancer
survivors.

Pregnancyafter breast cancer

Manywomen are abletobecomepregnant aftertreatment forbreast cancer. However,
sometreatments makeithardertoget pregnant.Ifyou thinkyou maywantto have children
oneday, orjust want to keepyouroptions open, thebest timeto talk toyour doctor about
fertilityis beforeyou begin breast cancertreatment.
Breast canceris most common in olderwomen. But ifyou areayoungerwoman who has
had breastcancer,you might havequestions about how breast cancer couldaffectyour
abilityto havechildren and whetherthereare anyextra risks.

Doesbreastcanceroritstreatmentaffectmyabilitytohave
ababy?
Sometreatments forbreast cancermayaffect awomans fertility(abilitytohaveababy). For
example, chemotherapyforbreast cancermight damagetheovaries, which can

sometimes causeimmediateordelayed infertility.Still, manywomenare ableto become

pregnant aftertreatment.Thebest timeto talk withyourdoctor about fertilityis before
startingbreast cancertreatment. Formore about how cancertreatment canaffect fertility,
seeFertilityandWomenWith Cancer.

Couldpregnancymakeitmorelikelymybreastcancerwill
comeback?
Manybreast cancers aresensitiveto estrogen, so therehas beenconcern that forwomen
who havehad breast cancer, thehigh hormonelevels that result from apregnancymight
increasethe chanceofthe cancercomingback. Studies haveshown, though, that
pregnancydoes not increasethe risk ofthecancercomingback aftersuccessful treatment.
Theresalso no proofthat breastfeeding afterbreast cancertreatment increases the risk of
recurrence.In fact, someresearch suggests having ahistoryofbreastfeeding might
actuallylowertherisk ofthe cancer comingback.

HowlongafterbreastcancertreatmentshouldIwaitbefore
becomingpregnant?
Ifyou want to have children, manydoctorsadvisebreast cancersurvivors to wait at least
2years afterall treatmenthas finished beforetryingtoget pregnant. Thebest length of
timeto wait is not clear, but 2years is thought tobe enough timeto find anyearlyreturn
ofthe cancer,which could affectyourdecision to becomepregnant. Keep in mind that this
adviceis not based on data from anyclinical trials. And somebreast cancers can
comebackafterthe2-yearmark, so everycaseisdifferent. Yourdecision should be based on
manythings, includingyourage, desireformorepregnancies, typeofbreast cancer, and
therisk ofthe cancercomingback early.

If I getpregnant,wouldmyhistoryofbreastcancerputmy
babyatrisk?
Thereis no proofthat awomans past breast cancerhasanydirect effecton herbaby.
Researchers have foundno increased rateofbirthdefects orotherlong-term health
concerns inchildren bornto women who havehadbreast cancer.

Couldbreastcancertreatmentaffectmyunbornbaby?
Ifyou arestill gettinganytypeoftreatment forbreast cancer, including chemotherapy,
hormonetherapy, ortargeted therapy, talk toyourdoctorbeforetryingto become pregnant.
Thesedrugs could affect agrowingfetus, so it is saferto wait to get pregnant

until all treatment is complete.Its also importantto rememberthat stoppingtreatment

earlycan increasetherisk ofthe cancergrowing or comingback. SeeBreast Cancer
During Pregnancyformoreinformation.

CanI breastfeedafterbreastcancertreatment?
Ifyou havehad breast surgeryand/orradiation,you mayhaveproblems breastfeeding from
the affected breast. Studies haveshown reduced milk production in that breast as well as
structuralchanges that can makeit difficult and painful forthebabyto latch onto thebreast.
Still, manywomen areableto breastfeed.
Ifyou arestill takinganymedicines to treatyourbreast cancer (suchas tamoxifen), its
veryimportant to talk withyourdoctorbeforetryingto breastfeed. Somedrugscan enter
thebreast milk and mightaffect thebaby.

Talktoyourdoctor
Ifyou haveorhavehad breast cancer and arethinkingabout having children, talk with
yourdoctor about how treatment could affectyour chances forpregnancy.This discussion
should also coverthe risk ofthecancercomingback.In manycases, counseling can
helpyousort through thechoices that comewith surviving breast cancer and planning
apregnancy.

Menopausalhormone therapyafter breast

cancer
Takinghormonetherapyto help with menopausesymptoms maynot besafe forwomen who
havehad breast cancer. This is aproblemformanywomen whoget symptoms such as hot
flashes from theircancertreatment, orjust becausetheyaregetting older.Ifyou arebothered
bymenopausesymptoms, talk toyourdoctor about otherwaysto get help.
Somepre-menopausal women havemenopausesymptoms as aresult ofchemotherapyor
ovarian ablation. Somehormonetherapydrugs used to treat breast cancer (such as
tamoxifen and aromataseinhibitors) can also causemenopausesymptoms.
Women who arepast menopausemight alsoget symptoms iftheyhad to stop takingpostmenopausal hormonetherapy(PHT),also called hormone replacement therapy(HRT).

CanI takemenopausalhormonetherapyafterbreast
cancer?
When women reach menopause, some chooseto takePHT, which is madeup of female
hormones (estrogen, sometimes alongwith progesterone)to help reducemenopause
symptoms. But doctors havebeen concernedabout women who havehad breast cancer
usingPHT, becauseoftheknown link betweenestrogen levels and breastcancergrowth.
In thepast, doctors oftenoffered PHT afterbreastcancertreatment to women suffering from
severesymptoms becauseearlystudies hadshown no harm. Butawell-designed clinical trial
(theHABITSstudy) found that breast cancersurvivors taking PHT were much
morelikelyto develop anew orrecurrent breast cancerthan womenwho werenot
takingthedrugs. Most doctors now feel that ifawoman was previouslytreated forbreast
cancer, takingPHT would beunwise.

Relievingmenopausalsymptomswithouthormonetherapy
Ifyou arehavingtroublewith menopausesymptoms, talk toyourdoctorabout other
ways besides PHT to help with specificsymptoms.
Soy products:Somedoctors havesuggested thatphytoestrogens (estrogen-like substances
fromcertain plant sources, suchas soyproducts)maybesaferthan the estrogens used in
PHT. Eatingsoyfoods seems to besafeforbreast cancersurvivors and might behelpful
forsomewomen, although its not clearifit can help relievemenopause symptoms. Women
canget higherdoses ofphytoestrogens in somedietarysupplements (such as
soyorisoflavonesupplements). However, not enough information is available
on thesesupplements to know forsureiftheyaresafe and iftheywork.Ifyou are
consideringtakingoneofthesesupplements, besureto talk withyour cancer careteam first.
Non-hormonemedicines:Drugs without hormoneproperties that maybehelpful in
treatinghotflashes include:
The antidepressant venlafaxine (Effexor)
Theblood pressuredrug clonidine
Thenervedrug gabapentin (Neurontin)
Ifyou aretakingtamoxifen, it's important to notethat some antidepressantsmayinteract
with tamoxifen and could makeit less effective.Askyourdoctor aboutanypossible
interactions between tamoxifen and anydrugsyouaretaking.
Acupuncture:Some research has suggested thatacupuncturemight behelpful in treating
hot flashes.

Second cancers after breast cancer

Women whovehad breast cancer can still get other cancers, although mostdont get
canceragain. Breast cancersurvivors are at higherrisk forgetting anotherbreast cancer, as
well as someothertypes of cancer.
Breast cancersurvivors can be affected byanumberofhealth problems, but often a major
concern is facing canceragain. Cancerthatcomes backaftertreatment is called a
recurrence. But somecancersurvivors develop anew, unrelated cancerlater. This is
called asecond cancer.
Unfortunately, beingtreated forbreast cancerdoesnt meanyou cantget another cancer.
Women who havehad breast cancercan still get thesametypes ofcancersthat other women
get.In fact, theymight be at higherrisk for certain types ofcancer.This can be dueto
anumberoffactors, such as:
A womansgenes, someofwhich might increaseher risk forboth breast and certain
other cancers
Havingotherfactors thatincreaseherrisk ofboth breast and other cancers
Possibleincreased risks from previous cancertreatments (such as radiation therapy,
chemotherapy, orhormonetherapy)
Women who havehad breast cancerhavean increased risk of:
A second breast cancer(This is different from thefirst cancer comingback.)
Salivary glandcancer
Esophaguscancer
Stomach cancer
Colon cancer
Uterinecancer
Ovarian cancer
Thyroidcancer
Soft tissue cancer(sarcoma)
Melanomaoftheskin
Acutemyeloid leukemia(AML)
Themost common second cancerin survivors ofbreast canceris anotherbreast cancer.
Thenew cancercan occurin theoppositebreast, as well as in thesamebreast forwomen who
weretreated with breast-conservingsurgery(such as alumpectomy).The risk ofa second
breast canceris increased no matterwhichtreatments awoman hashad. This means factors
likegenetics orhormonal risk factors might playa rolein these cancers.

Forsomeothersecondcancers, sharedgenetic riskfactors mayalso playarole. For

example, women with mutations in theBRCA genes haveahigh increasedrisk ofboth
breast cancer and ovariancancer.

Cancerslinkedtoradiationtreatment
Lung cancer:The risk oflungcanceris not increased in all women who havehad breast
cancer, but it is higherinwomen who had radiation therapyas part oftheirtreatment. The
increased risk is first seen about 10yearsafterradiation and gets higherovertime. The risk
oflung cancerafterradiation is even higherinwomen who smoke.
Sarcoma:Radiation therapyto thebreastalso increases therisk ofsarcomas ofblood vessels
(angiosarcomas),bone (osteosarcomas),and other connectivetissues. These cancers
aremost often seen in the remainingbreast area,chest wall, orarmthat had been treated
with theradiation therapy. This risk remains highereven 30yearsaftertreatment.
Certain bloodcancers:Breast radiation is linkedto ahigher risk ofleukemia and
myelodysplasticsyndrome. Overall, though, therisk is low less than halfapercent.

Cancerslinkedtochemotherapy
Thereis asmall increased risk ofdevelopingleukemia and myelodysplasticsyndrome
afterchemotherapy(chemo) for earlybreast cancer. The risk is higherifboth chemo and
radiation therapyaregiven. Somestudies have found thehighest risk in patients treated
with chemo drugs knownas alkylating agents, such as cyclophosphamide(Cytoxan). The
risk goes upas the amount ofthedrug givengoesup and as doseintensityincreases (when
doses ofthedrug aregivenclosertogether).

Cancerslinkedtotreatmentwithtamoxifen
Takingtamoxifen lowersthe chanceofhormonereceptor-positivebreast cancer coming
back.It also lowers the risk ofasecond breastcancer. Tamoxifen does, however, increase
the risk foruterinecancer (endometrialcancer and uterinesarcoma). Still, theoverall risk
ofuterinecancerin most women takingtamoxifen is low, and studies haveshown that
thebenefits ofthis drugin treatingbreast canceraregreaterthan the risk ofasecond
cancer.

Follow-upcare
After completingtreatment forbreastcancer,youshould still seeyourdoctor regularlyto look
forsigns that thecancerhascomeback orspread. See Livingas abreast cancer survivor
formoreon thetypes oftestsyou mightneed aftertreatment.

You should also follow theAmerican CancerSociety guidelines fortheearlydetection of

cancer, suchas those forlung, colorectal cancer, and cervical cancer. Screeningtests can
often find thesecancers early,when theyarelikelyto be easierto treat.In some cases, the
tests might even help prevent these cancers ifpre-cancers are foundand treated. For
women who havehad breast cancer, most expertsdo not recommend anyadditional
testingto look forsecondcancers unlessyou havesymptoms.
Letyourdoctorknowabout anynew symptoms orproblems, becausetheycould be caused
bythebreast cancer comingback orbyanew diseaseorsecondcancer.For example,
abnormal menstrual bleeding, such as bleedingorspotting aftermenopauseor between
periods, can beasymptom ofuterine cancer.

CanI lowermyriskofgettingasecondcancer?
Its not possibleto prevent all cancers, but there arestepsyou can taketo loweryourrisk
and stayas healthyas possible. Gettingtherecommended earlydetection tests, as
mentioned above, is onewayto do this.
Women who havehad breast cancershould do theirbest to stayawayfrom tobacco
products. Smokingincreases the risk ofmanycancers and might furtherincreasethe risk
ofsomeofthesecond cancers seen afterbreast cancer.
To help maintain good health, breastcancersurvivors should also:
Get to and stayat ahealthyweight
Keep physicallyactive
Eat ahealthydiet, with an emphasis on plant foods
Limit alcohol to no morethan 1 drink perday
Thesesteps mayalso lowerthe risk ofsomeotherhealth problems.
SeeSecond Cancers in Adults formoreinformation about causes ofsecondcancers.

Can I lowermyrisk of breast cancer

progressing or coming back?
Ifyou have(orhavehad)breast cancer,you probablywant to know iftherearethings you
can do that might loweryourrisk ofthecancergrowingorcomingback, such as
exercising, eating a certain typeofdiet, ortakingnutritional supplements. Fortunately,
breast canceris oneofthebest studied types ofcancerin this regard, and research has
shown therearesomethingsyou can do that might behelpful.

Gettingtoahealthyweight
Ifyou havehad breast cancer,gettingto and stayingatahealthyweight might help lower
yourrisk. A lot of research suggests that beingoverweight orobese (veryoverweight) raises
the risk ofbreast cancercomingback.It has also been linked with ahigherrisk of
gettinglymphedema,aswell as ahigherrisk ofdyingfrom breast cancer.
However, thereis less research to showwhetherlosingweight duringoraftertreatment can
actuallylowertherisk ofbreast cancerrecurrence.Largestudies arenow lookingat this issue.
This is complicated bythefact that manywomengain weight (without trying) duringbreast
cancertreatment, which itselfmightincrease risk.
Of course, forwomen who areoverweight,gettingto ahealthyweight canalso have
otherhealth benefits. Forexample, weight loss has been shown to improvequalityoflife
and physical functioning amongoverweight breastcancersurvivors. Gettingto ahealthy
weight might also loweryourrisk ofgettingsomeother cancers(including anew breast
cancer),as well as someother chronicdiseases.
Becauseofthepossiblehealth benefits oflosingweight, manyhealth careproviders now
encouragewomenwho areoverweight to get to and stayatahealthyweight. Still,its
important to discuss thiswithyourdoctorbeforetryingto loseweight,especiallyifyou arestill
gettingtreatmentorhavejust finished it. Yourhealth careteam can helpyou createaplan to
loseweight safely.

Beingphysicallyactive
Research suggests that women who get regularphysicalactivityaftertreatment maylive
longerthan thosewho dont. Amongbreast cancersurvivors, studies havefound a
consistent link between physicalactivityand alower risk ofbreast cancer recurrenceand
ofdyingfrom breast cancer. Physical activityhasalso been linked to improvements in
qualityoflife, physical functioning, and fewer fatiguesymptoms.
Its not clearexactlyhowmuch activitymight beneeded, but moreseems to bebetter.
Morevigorous activitymayalso bemorehelpful than less vigorous activity. But further
studies areneeded to follow up on these findings.
Somepeopleused to think that breast cancersurvivors with lymphedemashould avoid
certain arm exercises andvigorous activities. But studies have found that such physical
activityis safe.In fact, it might actuallylowertherisk oflymphedema, orimprove
lymphedema forwomenwho alreadyhaveit.
As with othertypes oflifestylechanges, its important to talk withyourtreatment team
beforestarting anew physical activityprogram. This will likelyincludemeetingwith a
physical therapist as well. Yourteam can helpyouplan aprogram that canbeboth safe and
effective foryou.

Eatingahealthydiet
Most research on possiblelinks between diet andbreast cancer recurrencerisk has looked
at broad dietarypatterns,ratherthan specificfoods.Ingeneral, its not clearif eating any
specifictypeofdiet canhelp loweryourrisk ofbreast cancer comingback. Studies have
found that breast cancersurvivors who eat diets high in vegetables, fruits,wholegrains,
chicken, andfish tend to livelongerthan thosewho eat diets that havemore refined sugars,
fats, red meats (such as beef, pork,and lamb), and processed meats (such as
bacon, sausage, luncheonmeats, and hot dogs). But its not clearifthis is dueto effects
on breast cancerorpossiblyto otherhealth benefits of eating ahealthydiet.
Two largestudies (known as WINSand WHEL)havelooked at theeffectsoflowering fat
intakeafterbeingdiagnosedwith earlystagebreast cancer. Onestudyfound that women on
alow-fat diethad asmall reduction in the risk of cancer recurrence, but these women had
also lost weight as aresult oftheirdiet, which might haveaffected the results.
Theotherstudydid not find alink between adiet low in fat and therisk of recurrence.
Manywomen havequestions about whethersoyproducts aresafetoeat afteradiagnosis
ofbreast cancer. Soyfoods are rich sources of compounds called isoflavones that can have
estrogen-likeproperties in thebody. However, some recent largestudies havenot found
that soyfood intake affects breast cancer recurrenceorsurvival rates. While eating
soyfoods doesnt seem to posea risk, the evidence regardingthe effects oftakingsoyor
isoflavonesupplements is not as clear.
Whilethelinks between specifictypes ofdiets and breast cancer recurrence arenot certain,
thereare clearlyhealth benefits to eating well. Forexample, diets that arerich in plant
sources areoftenanimportant part ofgetting to and stayingatahealthyweight.
Eatingahealthydiet canalso help loweryourrisk forsomeotherhealth problems, such as
heart disease and diabetes.

Dietarysupplements
Women often want to know ifthereareanydietaryornutritional supplements theycan
taketo help lowertheir risk. So far, no dietarysupplements havebeen shown to clearly
help lowerthe risk ofbreast cancerprogressingorcomingback. This doesnt mean that
nonewill help, but its important to know that nonehavebeen proven to do so.
Dietarysupplements arenot regulated likemedicines in theUnited States theydo not
haveto beproven effective (or even safe)beforebeingsold, although there arelimits on
what theyre allowed to claim theycan do.Ifyouarethinking about taking anytypeof
nutritional supplement, talk toyourhealth careteam. With good information and the
support ofyourhealth careteam,you maybe ableto safelyusethosethatmight helpyou while
avoidingthosethatcould beharmful.

Alcohol
Itsclearthat alcohol even as little as a few drinks aweek increases awomans risk of
getting breast cancer.Butwhether alcohol affects the risk ofbreast cancerrecurrenceis not
as clear.Drinking alcohol can raisethelevelsof estrogen in thebody,which in theory could
increasethe risk ofbreast cancer comingback. But thereis no strong evidence
from studies to support this.
As part ofits guidelines on nutrition and physicalactivityfor cancerprevention, the
American CancerSocietyrecommends that women who drink alcohol limit theirintake to
no morethan 1 drink adayto help lowertheirrisk ofgettingcertain types of cancer
(includingbreast cancer).But forwomen who have completed cancertreatment, the
effects of alcohol oncancerrecurrence risk arelargelyunknown.This issueis complicated
bythefact that low to moderate alcohol use (1 drink adayorless)has been linked with
alower riskofheart disease.
Becausethis issueis complex, its important to discuss it withyourhealth careteam,
takinginto accountyourrisk ofbreastcancerrecurrence (orgetting anewbreast cancer),
yourrisk ofheart disease, andyour risk ofotherhealth issues linked to alcohol use.

What's newin breast cancer researchand

treatment?
Researchers around theworld areworkingto find betterways to prevent,detect, and treat
breast cancer, and to improvethequalityoflifeofpatients and survivors. Someofthe
manyactiveareas of research include:
Breast cancercauses
Reducingbreast cancer risk
ManagingDCIS
New lab tests forbreast cancer
New imagingtests forbreast cancer
Breast cancertreatment

Causesofbreastcancer
Studies continueto uncoverlifestylefactors and habits, as well as inheritedgenes, that
affect breast cancerrisk. Herearea few examples:

Several studies arelookingat theeffect ofexercise, weightgain orloss, and diet on

risk.
Studies on thebest useofgenetictesting forBRCA1 and BRCA2 mutations continue at
a rapid pace.
Scientists are exploringhow common genevariations (small changes ingenes that are
not as significantas mutations)mayaffect breast cancerrisk. Genevariants typically
haveonlyamodest effect on risk, but when takentogethertheymaypotentiallyhave
alargeimpact.
Potential causes ofbreastcancerin the environment have also received more attention
in recentyears. Whilemuch ofthescienceon thistopicis still inits earliest stages,
this is an areaofactiveresearch.
A large, long-term studyfunded bytheNationalInstituteofEnvironmental Health
Sciences (NIEHS)is now beingdoneto help find the causes ofbreast cancer. Known as
theSisterStudy, it hasenrolled 50,000 womenwho havesisters with breast cancer. This
studywill follow thesewomen for at least 10years andcollect information about genes,
lifestyle, andenvironmental factors that maycausebreast cancer. An offshoot
oftheSisterStudy, theTwo SisterStudy, is designed to look at possible causes of
earlyonset breast cancer.To find out more about thesestudies, call 1-877-4-SISTER (1877-474-7837)orvisit theSisterStudywebsite(www.sisterstudy.org).

Reducingbreastcancerrisk
Researchers continueto look formedicines that might help lowerbreast cancer risk,
especiallyin women whoare at high risk.
Hormonetherapydrugs aretypicallyused to help treat breast cancer, but somemight
also help prevent it. Twodrugs, tamoxifen and raloxifene, are alreadyapproved for
this purpose, although concerns about sideeffectshavelimited theiruse. Aromatase
inhibitors suchas exemestane, anastrozole, and letrozole are also beingstudied to
reducethe risk ofbreastcancer.
Fenretinide, adrugrelated to vitamin A, is also beingstudied as awayto reducethe risk
ofbreastcancer.Inasmall study, this drug reduced breastcancerrisk as much as
tamoxifen.
Other clinical trials arelookingat breast cancer reduction as an unintendedeffect of
drugs used forother reasons. Drugscurrentlybeingresearched include
bisphosphonates (drugs forosteoporosis), and statins (such as atorvastatin and
lovastatin), which areused to lower cholesterol.
Dietarysupplements arealso beingstudied to seeiftheycan reducebreast cancer
risk. Thesehaveincludedgrapeseed extract, folate, omega-3 fattyacids, and vitamins

B6 andB12. Although somehuman studies ofthesesupplements havebeen

completed, verylittlehasbeen published in the availablemedical literatureto date.
Othersupplements nowbeingstudied includehydroxytyrosol (a component in olive
oil), curcumin, and omega-3 fattyacids (coupledwith weight loss).
This typeofresearch takes many years.It might besometimebeforemeaningful results on
anyofthesecompounds are available.

ManagingDCIS
In ductal carcinomain situ (DCIS), the abnormal cells arejust in thetop layers ofcells in
theducts within thebreast and havent invaded anydeeper.In somewomen, DCISturns into
invasivebreast cancer, orsometimes anareaofDCIScontains invasive cancer.In
somewomen, though, the cells just staywithin theducts and neverinvadedeeperor spread
to lymph nodes orotherorgans. Theuncertaintyabout howDCISwill behavecan makeit
hard to choosethebest treatments. Researchers arelookingforways to help with these
challenges.
Researchers arestudying theuseof computersand statistical methods to estimatethe odds
that awomans DCISwill becomeinvasive. Someofthesemethods arebased on
routinelyavailable clinical information about thepatient and herDCIS, whileothers also
includeinformation about changes in thegenes in hertumor cells. Decision aids are
another approach. Theyask awoman with DCISquestions that help herdecidewhich
factors (such as survival,preventingrecurrence, and side effects)sheconsiders most
important in choosingatreatment.
Another approach is to look at genes expressed bytheDCIS cells usingatest such as the
OncotypeDxDCIS Score. This test can beused to predict awomans chanceofDCIS
comingback oranew cancerdevelopingin thesamebreast ifshedoes not get radiation. So
far, though, it hasnt been studied well enough to predict how much someonewould
benefit from radiation aftersurgeryforDCIS.
Another recent areaof researchand debate among breast cancerspecialists is whether
changingthenameofDCISto onethat emphasizes that this is not an invasive cancer
could help somewomenavoid overlyaggressivetreatment.

Newerlabtests
Testsfor circulatingtumor cells(CTCs)
Researchers have found that in manywomen with breast cancer, cells maybreak away
from thetumor and entertheblood. These circulatingtumor cells can bedetected with
sensitivelab tests. Although thesetests can help predict which patients maygo on to have
their cancercomeback, it isnt clearthat theuseofthesetests can help patients live

longer.Forwomen withadvanced breast cancer, thesetests maypotentiallyhelp to tell if

treatments areworking.

Newerimagingtests
Newerimagingmethodsarenow being studied forevaluatingabnormalitiesthat maybe
breast cancers.

Scintimammography(molecular breastimaging)
In this test, aslightlyradioactivedrugcalled atracer is injected into avein.Thetracer
attaches to breast cancercells and is detected byaspecial camera.
This techniqueis still beingstudied to seeifit willbeuseful in findingbreast cancers.
Somedoctors believeitmaybehelpful in lookingat suspicious areasfound byregular
mammograms, but its exact roleis still unclear. Current research is aimedat improving
thetechnologyandevaluatingits usein specificsituations such as in thedensebreasts of
youngerwomen. Someearlystudies havesuggested that it maybe almost as accurateas
more expensivemagneticresonanceimaging(MRI)scans. At this time, however,
scintimammographyshould not beused as areplacement forscreeningmammograms.

Treatment
Oncoplasticsurgery
Breast-conservingsurgery(lumpectomyorpartialmastectomy)can often beused for earlystagebreast cancers. But forsomewomen, it can result in breasts ofdifferent sizes
and/orshapes.Ifthetumoris larger, it might not even bepossible, and amastectomy might
beneeded instead.Somedoctors areaddressingthis problem bycombiningcancer
surgeryand plasticsurgerytechniques, knownasoncoplasticsurgery. This typically
involves reshapingthebreast at thetimeoftheinitial surgery, and maymean operating
on theotherbreast as well to makethem more alike. This approach is still fairlynew, and
not all doctors arecomfortablewith it.

Targeted therapydrugs
Targeted therapiesareagroup ofnewerdrugs that specificallytarget genechanges in
cancercells that help the cells grow orspread.
Sometypes oftargeted therapydrugsarealreadybeingusedto treat breast cancer,
including:
Drugs that targetHER2, includingtrastuzumab(Herceptin), pertuzumab (Perjeta),
ado-trastuzumab emtansine (Kadcyla),and lapatinib (Tykerb)

Drugs thathelp hormone therapy work better,such as palbociclib (Ibrance) and

everolimus (Afinitor)
Manyothertypes oftargeted therapies arenow beingstudied foruseagainst breast
cancer, including:
PARPinhibitors:Thesedrugsaremost likelyto behelpful against cancers caused by
BRCA mutations, which includesomebreast cancers. Thesedrugs haveshown some
promisein earlyclinical trials treatingsometypesofbreast andothercancers. Further
studies arebeingdonetodeterminewhen thesedrugs might bemost helpful.
Anti-angiogenesis drugs:Forcancers togrow, blood vessels must develop to nourish
the cancercells. This process is called angiogenesis.Lookingat angiogenesis in breast
cancersamples might help predict prognosis. Although onedrugthat blocks
angiogenesis, known as bevacizumab (Avastin), turned out to not beveryhelpful in
treating advanced breastcancer, this approach still mayproveuseful in breast cancer
treatment. Several otheranti-angiogenesis drugs arebeingtested in clinicaltrials.
Other targeted drugs:Otherpotential targets fornew breast cancerdrugshavebeen
identified in recentyears.Drugs based on thesetargets arenow beingstudied, but most
arestill in the earlystages of clinical trials.

Bone-directed treatments
Ifbreast cancerspreads, it often goes to thebones.Somedrugs can help treat thespread of
cancerto thebones, and might even help prevent it.
Bisphosphonates:Thesedrugsareused to help strengthen andreducetherisk of
fractures in bones that havebeen weakened bymetastaticbreast cancer. Examples
includepamidronate(Aredia) and zoledronicacid(Zometa).
Somestudies havesuggested that zoledronic acidmayhelp othertreatments, such as
hormonetherapyand chemo, work better.In onestudyofwomen beingtreated with chemo
beforesurgery, tumors in thewomen gettingzoledronicacid with chemo shrank
morethan thosein thewomen treated with chemoalone.
Otherstudies havelooked at the effect ofgivingzoledronic acid with otheradjuvant
treatments (like chemo orhormonetherapy). Somestudies haveshown thatthis approach
helped lowertherisk ofthe cancercomingback, but others did not. The results ofone
studylinked theuseofthesedrugs with adjuvant chemo with an increased risk ofbreast
cancerrecurrenceinyoungerwomen. Overall, thedatadoes not support making
bisphosphonates part ofstandard therapyforearly-stagebreast cancer.
Denosumab(Xgeva):This drugcan also beusedto help strengthen and reducethe risk of
fractures in bones thathavebeen weakened bymetastaticbreastcancer.It is being studied
to seeifit can help adjuvant treatments work better.

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