In the United States, breast cancer is the most common cancer occurring in women (excluding cancers of the skin) and the second most common cause of death from cancer in women, after lung cancer. Men can also develop breast cancer, but male breast cancer is rare, accounting for less than 1% of all breast cancer cases.

The breast is mainly composed of fatty tissue. Within this tissue is a network of lobes, which are made up of tiny, tube-like structures called lobules that contain milk glands. Tiny ducts connect the glands, lobules, and lobes and carry the milk from the lobes to the nipple, located in the middle of the areola (darker area that surrounds the nipple of the breast). Blood and lymph vessels run throughout the breast; blood nourishes the cells, and the lymph system drains bodily waste products. The lymph vessels connect to lymph nodes.

About 90% of all breast cancer cases start in the ducts or lobes. Almost 75% of all breast cancers begin in the cells lining the milk ducts and are called ductal carcinomas. Cancer that begins in the lobules is called lobular carcinoma. If the disease has spread outside of the duct and into the surrounding tissue, it is called invasive or infiltrating ductal carcinoma. If the disease has spread outside of the lobule, it is called invasive or infiltrating lobular carcinoma. Disease that has not spread is called in situ, meaning "in place." The course of in situ disease, as well as its treatment, depends on whether it is ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS).

Currently, oncologists recommend that DCIS, which accounts for the majority of in situ breast cancers, be surgically removed to help prevent the cancer from changing into an invasive breast cancer and potentially spreading to other parts of the breast or the body. In addition to surgery, radiation therapy and hormone therapy may be recommended for DCIS.

LCIS is not considered cancer and is usually monitored by the doctor. LCIS is a risk factor for breast cancer (see Risk Factors section).

Other, less common cancers of the breast include medullary, mucinous, tubular, metaplastic, or papillary breast cancer. Inflammatory breast cancer is a faster-growing type of cancer that accounts for about 1% to 5% of all breast cancers. It may be misdiagnosed as a breast infection because there is often swelling of the breast and redness of the breast skin. Paget's disease is a type of in situ cancer that can begin in the ducts of the nipple. The skin often appears scaly and may be itchy.

Cancer may begin as a single, genetically abnormal cell. As this one cell divides, it eventually becomes a tumor (a mass of cells) and develops a blood supply to nourish its continued growth. At some point, cells may break off from the primary mass and move to other parts of the body in a process called metastasis.

Breast cancer spreads when breast cancer cells move to other sites in the body through the blood vessels and/or lymph vessels. A common site of spread is the lymph nodes. The lymph nodes can be axillary (located under the arm), cervical (located in the neck), or supraclavicular (located just above the collarbone). The most common sites of distant metastasis are the bones, lungs, and liver. Less commonly, breast cancer may spread to the brain. The cancer can also recur (come back after treatment) locally in the skin, in the same breast (if it was not removed as part of treatment), other tissues of the chest, or elsewhere in the body.

Sometimes, breast cancer is diagnosed and treated before metastasis occurs. According to the latest data from the National Cancer Institute (NCI), 61% of breast cancers are diagnosed while the cancer is still in the breast, 31% are diagnosed after the cancer has spread to nearby lymph nodes or just outside the breast, and 6% are diagnosed once the cancer has metastasized.

Statistics

In 2008, an estimated 182,460 women in the United States will be diagnosed with invasive breast cancer, and 67,770 women will be diagnosed with in situ breast cancer. An estimated 1,990 men in the United States will be diagnosed with breast cancer. It is estimated that 40,930 deaths (40,480 women, 450 men) from this disease will occur this year.

If the cancer is limited to the breast, the five-year relative survival rate (percentage of patients who survive at least five years after the cancer is detected, excluding those who die from other diseases) is 98%. If the cancer has spread to the regional lymph nodes, the five-year relative survival rate is 84%. If the cancer has spread to a distant site, the five-year relative survival rate is 27%. Even if the cancer is found at a more advanced stage, new therapies enable many people with breast cancer to experience the same quality of life as before their diagnosis.

It is important to note that these are averages, and each individual’s risk depends upon numerous factors including the size of the tumor and the number of positive lymph nodes (lymph nodes that contain cancer). The survival rate is higher and the chance of recurrence is lower for smaller tumors with negative lymph nodes (lymph nodes that do not contain cancer). The recurrence rate increases with an increase in tumor size and number of positive lymph nodes.

Since 1990, the number of women who have died of breast cancer has declined steadily each year. In women younger than 50, there has been a decrease of 3.3% per year; in women age 50 and older, the decrease has been 2% per year. Currently, there are about two and a half million women living in the United States who have been diagnosed with and treated for breast cancer.

Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of cases of this type of cancer in the United States each year, but the actual risk for a particular individual may differ. It is not possible to tell a person how long he or she will live with breast cancer. Because the survival statistics are measured in five-year (or sometimes one-year) intervals, they may not represent advances made in the treatment or diagnosis of this cancer.

Statistics adapted from the American Cancer Society's publication, Cancer Facts & Figures 2008.

To learn about the cancer terms used in this section, read the Cancer.Net Feature: Cancer Terms to Know: Basic Oncology Terms

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A risk factor is anything that increases a person's chance of developing cancer. Some risk factors can be controlled, such as smoking, and some risk factors cannot be controlled, such as age and family history. Although risk factors can influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and communicating with your doctor can help you make more informed lifestyle and health-care choices.

Many cases of breast cancer occur in women with no obvious risk factors. This means that women need to be aware of possible changes in their breasts and schedule clinical breast examinations and mammograms (x-rays of the breast that can detect tumors too small to be felt). It is likely that multiple risk factors influence the development of breast cancer. The following factors can raise a person's risk of developing breast cancer:

Age. The risk of developing breast cancer increases as a woman ages, with most cases developing in women over 50.

Race. Although white women are more likely to develop breast cancer, black women are more likely to die from the disease. Other reasons for survival differences are unclear and probably involve both socioeconomic and biologic factors.

Personal history of breast cancer. A woman who has had breast cancer in one breast has a 1% to 2% increased risk per year for developing breast cancer in her opposite breast.

Family history of breast cancer. Women who have a first-degree relative (mother, sister, daughter) diagnosed with breast cancer are at increased risk for the disease. More than one first-degree relative with breast cancer elevates that risk, especially if the cancer occurred before menopause.

Genetic predisposition. Mutations to the breast cancer genes 1 or 2 (BRCA1 or BRCA2) are associated with increased breast cancer risk. Blood tests are available to test for known mutations to these genes, but are not recommended for everyone and only after a person has received appropriate genetic counseling. Researchers estimate that breast cancers with genetic causes make up only 5% to 10% of all breast cancers. Learn more about The Genetics of Breast Cancer.

Personal history of ovarian cancer. Because ovarian cancer is also associated with exposure to hormones, a history of ovarian cancer can increase a woman's risk of breast cancer. Some breast cancer gene mutations, such as BRCA1 and BRCA2, may increase the risk of both ovarian and breast cancers.

Estrogen exposure. Estrogen is a hormone in women that controls the development of secondary sex characteristics (such as breast development). A woman's production of estrogen decreases at menopause. Doctors think that exposure to estrogen for a long time may increase breast cancer risk.

• Women who began menstruating before age 12 or went through menopause after age 55 have a higher risk of breast cancer because their breast cells have been exposed to estrogen for longer periods.
  
  
• Women who have their first pregnancy after age 30 or who have never had a full-term pregnancy have a higher risk of breast cancer. Pregnancy may protect against breast cancer, because it pushes breast cells into their final phase of maturation.
  
  
• Recent use (within the past five years) of hormone replacement therapy (HRT) and long-term use (several years or more) of HRT increases a woman's risk of breast cancer.

Atypical hyperplasia of the breast. This condition increases the risk of breast cancer and is characterized by abnormal, but not cancerous, cells found in a breast biopsy.

Lobular carcinoma in situ (LCIS). As explained in the Overview section, this condition describes abnormal cells found in the lobules or glands of the breast. LCIS increases the risk of developing invasive breast cancer (cancer that spreads into surrounding tissues). Talk with your doctor about the best way to monitor this condition.

Lifestyle factors. As with other types of cancer, studies continue to show that various lifestyle factors may contribute to the development of breast cancer.

• Obesity. Recent studies have shown that being obese or even overweight increases a woman's risk of breast cancer.
  
  
• Lack of exercise. Exercise lowers hormone levels and boosts the immune system; lack of exercise contributes to obesity.
  
  
• Alcohol use. Drinking more than one alcoholic drink per day may raise the risk of breast cancer.

Radiation. High doses of radiation may increase a woman's risk of breast cancer. An increased risk of breast cancer has been observed in long-term survivors of atomic bombs, people with lymphoma treated with radiation therapy to the chest, people undergoing large numbers of x-rays (such as for tuberculosis or to treat residual thymic disease or acne), nonmalignant (noncancerous) conditions of the spine, and children treated with radiation therapy for ringworm.

Currently, there are no proven means to prevent breast cancer, although there are ways to reduce the risk of breast cancer in some women.

• For women with especially strong family histories of breast cancer (such as BRCA mutations), a prophylactic mastectomy (preventive removal of the breasts) may be considered. This appears to reduce the risk of developing breast cancer by at least 95%.



• Women who are at higher than normal risk for developing breast cancer may consider chemoprevention (the use of drugs to reduce breast cancer risk). One such drug is tamoxifen (Nolvadex), which is a selective estrogen receptor modulator (SERM). A SERM is a medication that blocks estrogen receptors in some tissues and not others. Tamoxifen can reduce a woman's risk of developing breast cancer and can reduce the risk of the cancer recurring once a woman has been treated for breast cancer. Like estrogen, tamoxifen helps increase bone density in postmenopausal women and protects the cardiovascular system. However, unlike estrogen, SERMs do not promote the development of breast cells into cancer cells, and they may increase the risk of blood clots and uterine (endometrial) cancer.

For most women, regular mammography and clinical breast examinations can help find early signs of breast cancer. In addition, women should become familiar with their own breasts. Checking your own breasts for lumps with a breast self-examination may help if performed correctly. Talk with your doctor for more information.

The STAR trial

The Study of Tamoxifen and Raloxifene (STAR) trial, launched in May 1999, is a breast cancer risk reduction trial. The STAR trial compared the effectiveness of two SERMs, tamoxifen and raloxifene (Evista), in reducing the risk of developing breast cancer in postmenopausal women over age 35 with an increased risk of developing breast cancer. The trial was conducted by the National Cancer Institute (NCI) and the National Surgical Adjuvant Breast and Bowel Project (NSABP). A recent analysis of the clinical trial data shows that both tamoxifen and raloxifene reduce the risk of invasive breast cancer by about 50% in women at high risk for the disease (this is the relative risk; the absolute risk for any woman taking these medications to lower the risk of breast cancer is 2% to 3%), and neither drug significantly impairs quality of life. Because these drugs are associated with different side effects, women should discuss the risks and benefits of each drug with their doctors.

Screening guidelines

The U.S. Preventive Services Task Force (USPSTF) recommends that women 40 to 75 years old undergo mammography every one to two years, and the American Cancer Society (ACS) recommends yearly mammography. Mammography is the best tool doctors have to screen for breast cancer and can detect tumors that are too small to be felt. All women should talk with their doctors about mammography and decide on an appropriate screening schedule.

Occasionally, mammograms may miss a cancer. Other methods of breast imaging, such as ultrasound and magnetic resonance imaging (MRI), are not routinely used for screening purposes. However, they may be helpful in evaluating women at a higher risk for breast cancer, including women with a BRCA mutation and women who received radiation therapy for Hodgkin lymphoma. These other screening methods may also be used for those with a suspicious finding on physical examination. If there are suspicious findings on physical examination, further evaluation is necessary, even if the mammogram is interpreted as normal.

The USPSTF and ACS differ on their recommendations for clinical breast examination. The USPSTF recommends a clinical breast examination along with mammography, and the ACS recommends a clinical breast examination every one to three years. Breast self-examination has not been shown to lower deaths from breast cancer, but it is important for women to become familiar with their breasts so that they can be aware of any changes. Women are encouraged to discuss the frequency of screening with their doctors.

Women with breast cancer may experience the following symptoms. Sometimes, women with breast cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. If you are concerned about a symptom on this list, please talk with your doctor.

However, most women who develop breast cancer have no signs or symptoms. The signs and symptoms to look for include:

• New lumps (many women normally have lumpy breasts) or a thickening in the breast or under the arm



• Nipple tenderness, discharge, or physical changes (such as a nipple turned inward or a persistent sore)



• Skin irritation or changes, such as puckers, dimples, scaliness, or new creases



• Warm, red, swollen breasts with a rash resembling the skin of an orange (called peau d'orange)



• Pain in the breast (usually not a symptom of breast cancer, but should be reported to a doctor)

Doctors use many tests to diagnose cancer and determine if it has metastasized. Some tests may also find out which treatments may be the most effective. For most types of cancer, a biopsy (the removal of a small amount of tissue for examination under a microscope) is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:

• Age and medical condition
• The type of cancer
• Severity of symptoms
• Previous test results

The diagnosis of breast cancer usually begins when a woman or doctor discovers a mass or abnormal calcification (tiny spot of calcium usually found on an x-ray) on a screening mammogram, or an abnormality in the woman's breast by clinical examination or self-examination. Several tests may be done to confirm a diagnosis of breast cancer. Not every person will have all of these tests.

In addition to screening mammography, the following tests may be used to diagnose breast cancer:

Imaging tests

Diagnostic mammography. Diagnostic mammography is similar to screening mammography except that more views (pictures) of the breast are taken, and it is often used when a woman is experiencing signs, such as nipple discharge or a new lump. Diagnostic mammography may also be used if something suspicious is found on a screening mammogram.

Ultrasound. An ultrasound uses high-frequency sound waves to create an image of the breast tissue. An ultrasound may distinguish between a solid mass, which may be cancer, and a fluid-filled cyst, which is usually not cancer.

MRI. An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. An MRI may be used once a woman has been diagnosed with cancer to check the other breast for cancer, but the benefit of this is controversial. It may also be used for screening. According to the American Cancer Society (ACS), women at high risk of breast cancer (for example, women with BRCA gene mutations or a strong family history of breast cancer) should receive MRI screening along with a mammogram. MRI may often be better at seeing a small mass within a woman's breast than a mammogram or ultrasound, especially for women with very dense breast tissue, but has a higher rate of false-positive test results (a test result that indicates cancer when there is no cancer present) and may result in more biopsies. In addition, an MRI does not show calcifications, which could indicate in situ breast cancer. Talk with your doctor for more information.

Surgical tests

Biopsy. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed from the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluates cells, tissues, and organs to diagnose disease).

• Image guided biopsy is used when a distinct lump can't be felt. It can be done with a fine needle aspiration biopsy (FNAB, uses a small needle to remove the tissue sample), stereotactic core biopsy (uses x-rays to find the area of tissue to be removed), or a vacuum-assisted biopsy (uses a thicker needle to remove multiple large cores of tissue). During this procedure, a needle is guided to the area of concern with the help of mammography, ultrasound, or MRI. A small metal clip may be put into the breast to mark the site of biopsy, in case the sample tissue proves cancerous and additional surgery is required. An advantage of this technique is that a patient may only need one operation for treatment or staging.
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• Core biopsy can obtain tissue or FNAB can obtain cells in masses that can be felt, and these can then be analyzed for presence of malignant cells.
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• Surgical biopsy removes the largest amount of tissue. This biopsy may be incisional (removal of part of the lump) or excisional (removal of the entire lump).

If cancer is diagnosed, a second surgery may be needed to get a clear margin (area of tissue around the tumor where there are no cancer cells) and/or remove lymph nodes.

Doctors may also test the tissue from a biopsy to help guide treatment decisions. The tests include:

• Tumor features. Examination of the tumor under the microscope determines if it is invasive or in situ; ductal or lobular; grade (how different the cancer cells look from healthy cells); and whether the cancer has spread to the blood vessels or lymph vessels. The margins of the tumor are also examined.
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• Estrogen receptor (ER) and progesterone receptor (PR) tests. Breast cancer cells with these receptors depend on estrogen and progesterone to help them grow. The presence of these receptors helps determine both the patient's prognosis (chance of recovery) and whether the cells are likely to respond to hormone therapy. Generally, ER-positive or PR-positive tumors respond to hormone therapy.
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• HER2/neu tests. There is too much of the protein HER2 in about 25% of breast cancers. The HER2 status helps determine whether a drug called trastuzumab (Herceptin) might be useful for treating breast cancer. Read more in the ASCO Patient Guide: HER2 Testing in Breast Cancer.
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• Genetic description of the tumor. Tests that look at the biology of the tumor are becoming more common to understand more about a woman's breast cancer. Oncotype Dx is a type of test that measures the risk of distant recurrence (return of the cancer in a place other than the breast) at 10 years for women with stage I or stage II node-negative, ER-positive breast cancer that may be treated with hormone therapy. This information may also be used to plan treatment. Talk with your doctor for more information.

Blood tests

The doctor may also require blood tests to learn more about the cancer.

Complete blood count (CBC). CBC is a blood test done to determine the following:

• Hemoglobin level (the amount of oxygen in red blood cells)
• Hematocrit level (the percentage of red blood cells in whole blood)
• The number of white blood cells (cells that help to fight infection)
• The number of platelets (cells that help blood to clot as necessary)
• Differential (the percentage of several types of white blood cells)

Alkaline phosphatase levels. High levels of this enzyme could indicate the disease has spread to the liver, bone, or bile ducts.

Total bilirubin count, serum glutamic-oxaloacetic transaminase (SGOT), and serum glutamate pyruvate transaminase (SGPT) levels. These tests evaluate liver function. High levels of any of these tests can indicate liver damage, a signal of possible spread to that organ.

Tumor marker tests. A tumor marker (also called a serum marker or biomarker) is a substance found in a person's blood, urine, or body tissue. The presence of a tumor marker, or having higher or lower than normal levels of a tumor marker, may indicate an abnormal process in the body, which could be because of cancer or a noncancerous condition. Tumor markers may be used for diagnosis, treatment planning, and/or treatment monitoring. For more information, read the ASCO Patient Guide: Tumor Markers for Breast Cancer

Additional tests

The doctor may order additional tests (depending on the individual's medical history and results of the physical examination) to assess the stage of the cancer. Read the staging section below for more information. These tests are not recommended for all patients.

• A chest x-ray may be used to look for cancer that has spread from the breast to the lung.
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• A bone scan may be used to look for spread to the bones. During a bone scan, a radioactive tracer is injected into the patient's vein, where it collects in areas of the bone and is detected by a scanner.
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• A computed tomography (CT or CAT) scan may be used to look for distant tumors. A CT scan creates a three-dimensional picture of the inside of the body using a series of x-ray pictures taken from many different angles. A computer compiles these images into a detailed, cross-sectional view.
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• A positron emission tomography (PET) scan may be used to determine whether the cancer has spread. In a PET scan, radioactive sugar molecules are injected into the body. Cancer cells absorb sugar more quickly than normal cells, so they light up on the PET scan. PET scans are often used to complement information gathered from CT scan, MRI, and physical examination.

To learn about the terms used in this section, read the Cancer.Net Feature: Cancer Terms to Know: Newly Diagnosed.

To learn more about what to expect during common diagnostic tests, read Cancer.Net: Tests and Procedures.

Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and if it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis. There are different stage descriptions for different types of cancer.

One tool that doctors use to describe the stage is the TNM system. This system uses three criteria to judge the stage of the cancer: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to other parts of the body. The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer so doctors can work together to plan the best treatments.

TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:

• How large is the primary tumor and where is it located? (Tumor, T)
  
  
• Has the tumor spread to the lymph nodes? (Node, N)
  
  
• Has the cancer metastasized to other parts of the body? (Metastasis, M)

Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are divided into smaller groups that help describe a patient's condition in more detail.

TX: The primary tumor cannot be evaluated.

T0: There is no evidence of cancer in the breast.

Tis: Refers to carcinoma (cancer) in situ. In this case, the cancer is confined within the natural boundaries of the breast tissue and has not spread into the surrounding tissue of the breast. There are three types of breast carcinoma in situ:

T1: A tumor in the breast is 2 centimeters (cm) or smaller in size at its widest dimension.

T1mic: Microinvasion, or micrometastases, means a few cancer cells have spread to surrounding tissue, but none larger than 0.1 cm.

T1a: The tumor is larger than 0.1 cm but smaller than 0.5 cm.

T1b: The tumor is larger than 0.5 cm but smaller than 1 cm.

T1c: The tumor is larger than 1 cm but not larger than 2 cm.

T2: The tumor is larger than 2 cm but not larger than 5 cm.

T3: The tumor is larger than 5 cm.

T4: The tumor has spread to the chest wall or to the skin or is diagnosed as inflammatory breast cancer.

T4a: The tumor has spread into the chest wall.

T4b: There is edema (swelling), thickening of the skin (as in peau d'orange), or ulceration (a sore, painful area where the breast skin/tissue is breaking down) of the breast skin or surrounding skin nodules of the same breast.

T4c: There are signs of both T4a and T4b.

T4d: Refers to inflammatory carcinoma. This is an aggressive type of breast cancer where the breast is red, swollen, and warm.

Node. The "N" in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes located under the arm, above and below the collarbone, and under the breastbone are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes.

NX: The lymph nodes cannot be assessed.

N0: No cancer was found in the lymph nodes.

N1: The cancer has spread to one to three axillary lymph nodes.

N2: The cancer has spread to four to nine lymph nodes under the arm or to the internal mammary lymph nodes (lymph nodes to the right or left of the sternum [breastbone] on the inside of the chest) without axillary node involvement.

N2a: The cancer has spread to four to nine lymph nodes under the arm (at least one tumor deposit is larger than 2 mm).

N2b: The cancer has spread only to the internal mammary lymph nodes.

N3: The cancer has spread to 10 or more lymph nodes under the arm or to the infraclavicular lymph nodes (located under the collarbone) or to the internal mammary nodes with axillary node involvement.

N3a: The cancer has spread to 10 or more lymph nodes under the arm or to the infraclavicular lymph nodes.

N3b: The cancer has spread to internal mammary nodes and axillary nodes.

N3c: The cancer has spread to the supraclavicular lymph nodes.

If there is cancer in the lymph nodes, it also helps doctors to plan treatment to know how many lymph nodes are involved. The pathologist can determine the number of lymph nodes affected by cancer.

Distant metastasis. The "M" in the TNM system indicates whether the cancer has spread to other parts of the body.

MX: Distant spread cannot be assessed.

M0: The disease has not metastasized.

M1: There is metastasis to another part of the body.

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications.

Stage 0: Ductal carcinoma in situ is cancer that has not spread past the ducts or lobules of the breast (the natural boundaries). It is also called noninvasive cancer.

Stage I: The tumor is small and has not spread to the lymph nodes (T1, N0, M0).

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Stage IIa: Any one of these conditions:

• The tumor is smaller than or equal to 2 cm and has spread to the axillary lymph nodes under the arm (T1 or T1mic, N1, M0).
  
  
• The tumor is larger than 2 cm but not larger than 5 cm and has not spread to the axillary lymph nodes (T2, N0, M0).
  
  
• There is no evidence of a tumor in the breast, but there is cancer in the axillary lymph nodes (T0, N1, M0).

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Stage IIb: Any one of these conditions:

• The tumor is larger than 2 cm but not larger than 5 cm and has spread to the axillary lymph nodes (T2, N1, M0).
  
  
• The tumor is larger than 5 cm but has not spread to the axillary lymph nodes (T3, N0, M0).

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Stage IIIa: Any of these conditions:

• The tumor is smaller than 5 cm and has spread to the axillary lymph nodes (T1, N2, M0 or T2, N2, M0).
  
  
• The tumor is larger than 5 cm and has spread to the axillary lymph nodes (T3, N1, M0 or T3, N2, M0).

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Stage IIIb: The tumor has spread to the chest wall or caused swelling or ulceration of the breast or is diagnosed as inflammatory breast cancer. It may or may not have spread to the lymph nodes under the arm, but has not spread to other parts of the body (T4, N0, M0; T4, N1, M0; or T4, N2, M0).

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Stage IIIc: A tumor of any size has not spread to distant parts of the body but has spread to the lymph nodes in the N3 group (any T, N3, M0).

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Stage IV: The tumor can be any size and has spread to distant sites in the body, usually the bones, lungs or liver, or chest wall (any T, any N, M1).

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Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual Sixth Edition (2002) published by Springer-Verlag New York, www.springer-ny.com.

The treatment of breast cancer depends on the size and location of the tumor, whether the cancer has spread, and the person's overall health. In many cases, a team of doctors will work with the patient to determine the best treatment plan.

Even though the doctor will tailor the treatment for breast cancer specifically for each patient, there are some general steps for treating breast cancer. Primarily, the goal of the initial therapy for early-stage disease is to remove the tumor and have clear tissue around the tumor. Therefore, doctors will recommend surgery to remove the tumor. Most of the time radiation therapy to the remaining breast tissue will be recommended. There are certain situations where radiation therapy may be deferred (for example, in patients with other serious medical problems) for hormone therapy alone or no additional therapy.

The next step in the management of early-stage breast cancer is to reduce the risk of the disease coming back and getting rid of any remaining cancer cells. If a tumor is large or lymph nodes are involved, the doctor may recommend additional therapy, such as radiation therapy, chemotherapy, and/or hormone therapy. Recurrent cancer is treated in a variety of ways.

When planning the treatment for breast cancer, the doctor will consider many factors, including:

• The stage and grade of the tumor
  
  
• The tumor's hormone receptor status (ER, PR) and HER2/neu status (see Diagnosis)
  
  
• The patient's age and general health
  
  
• The patient's menopausal status
  
  
• The presence of known mutations to breast cancer genes

The biology of breast cancer affects its behavior and the treatment. Some tumors are small but grow fast, while others are large and grow slower.

Surgery

Generally, the smaller the tumor, the more surgical options a patient has. The types of surgery include the following:

• A lumpectomy removes the tumor and a small, clear (cancer-free) margin of tissue around the tumor. For DCIS and an invasive cancer, follow-up radiation therapy to the affected area is usually given. A lumpectomy may also be called a partial mastectomy or a segmental mastectomy.
  
  
• A total mastectomy removes the entire breast, but not the underarm lymph nodes. This surgery is also called a simple mastectomy.
  
  
• A modified radical mastectomy removes the breast and underarm lymph nodes.
  
  
• Axillary lymph node dissection involves the surgeon removing lymph nodes from under the arm and having them examined by a pathologist for cancer cells. The actual number of nodes removed may vary.
  
  
• Sentinel lymph node biopsy is a procedure in which the surgeon finds and removes the sentinel (first) lymph node (generally one to three nodes) that receives drainage from the breast. The pathologist then examines it for cancer cells. To identify the sentinel lymph node, the surgeon injects a dye and/or a radioactive tracer into the area around the nipple. The dye or tracer will travel to the lymph nodes, arriving at the sentinel node first. The surgeon can find the node when it turns color (if the dye is used) or emits radiation (if the tracer is used). Sentinel lymph node biopsy often has a lower risk of lymphedema (swelling of the arm) than axillary lymph node dissection. If the sentinel node is cancer-free, research has shown that there is a good possibility that the subsequent nodes will also be free of cancer and no further surgery of the lymph nodes is performed. If the sentinel lymph node shows cancer is present, then the surgeon will perform an axillary lymph node dissection. For more information, read the ASCO Patient Guide: Sentinel Lymph Node Biopsy in Early Stage Breast Cancer.
  
  
• Women who undergo a mastectomy may wish to consider breast reconstruction, which is surgery to rebuild the breast. Reconstruction may be done with tissue from another part of the body, or with synthetic implants. A woman may be able to have this done at the time of mastectomy or at some point in the future.

Most patients with invasive cancer will undergo either sentinel lymph node biopsy or an axillary lymph node dissection. For those with sentinel nodes that indicate cancer, an axillary lymph node dissection is still considered necessary. Research is underway to assess if this continues to be true.

To summarize, surgical treatment options include the following:

• Lumpectomy or partial mastectomy and radiation therapy
  
  
• Total mastectomy, with or without immediate reconstruction, with or without sentinel node biopsy and possible axillary lymph node dissection
  
  
• Modified radical mastectomy with or without immediate reconstruction

For invasive breast cancer, the combination of lumpectomy or partial mastectomy and radiation therapy has been proven in clinical trials to be as effective as a modified radical mastectomy.

Women are encouraged to talk with their doctors about which surgical option is right for them. More aggressive surgery (such as a mastectomy) is not always better and may result in additional complications.

For more information, read the Cancer.Net Feature: After a Mastectomy, Cancer.Net Feature: Breast Reconstruction, and Cancer.Net Feature: Choosing a Breast Prosthesis.

Adjuvant therapy

Adjuvant therapy is treatment that is given in addition to surgery to decrease the risk of the breast cancer returning. Adjuvant therapies include radiation therapy, chemotherapy, hormone therapy, and targeted therapy. They are intended to eliminate any potential breast cancer cells that may remain after the first treatment. Adjuvant therapy decreases the risk of recurrence, but does not necessarily eliminate it.

Along with staging, other sophisticated tools can help determine prognosis and help you and your doctor make decisions about adjuvant therapy. The website Adjuvant! Online (www.adjuvantonline.com) is one such tool that your doctor can access to interpret a variety of prognostic factors. This website should only be used with the interpretation of your doctor.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. Radiation therapy is given regularly for a number of weeks following a lumpectomy or partial mastectomy to eliminate any remaining cancer cells near the tumor site or elsewhere within the breast. Radiation therapy is also recommended for some women after a mastectomy depending upon the size of their tumor, number of cancerous lymph nodes under the arm, and width of the tissue margin around the tumor removed by the surgeon. Radiation therapy may be given before surgery to shrink a large tumor and make it easier to remove, although this approach is rare.

Radiation therapy is effective in reducing the chance of breast cancer returning in both the breast and the chest wall. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation therapy given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. In addition, there are balloon catheters that can deliver radiation therapy (called Mammosite).

Standard radiation therapy after a lumpectomy or partial mastectomy has been external-beam radiation therapy given for 5 days (Monday through Friday) for 6 to 7 weeks. This usually includes radiation therapy to the whole breast first for 4.5 to 5 weeks, followed by a more focused treatment to the site of the tumor bed in the breast for the remaining treatments. Standard radiation therapy after a mastectomy is given to the chest wall for 5 days (Monday through Friday) for 5 to 6 weeks. If there is evidence of cancer in the underarm lymph nodes, radiation therapy may also be given to the lymph node areas in the neck or underarm near the breast or chest wall.

There has been growing interest in newer radiation methods to shorten the length of treatment from 6 to 7 weeks to periods of 3 to 4 weeks or as little as one week. There are two common methods:

• In one method, a higher daily dose is given to the whole breast each day so that the overall length of treatment is shortened to 3 to 4 weeks. This can also be combined with a higher dose given to the tumor bed in the breast either during or after the whole breast radiation treatments. Clinical trials from Canada and the United Kingdom have shown that these shorter schedules can be equally accepted by patients with the same cancer control rates and side effects as longer radiation treatment schedules. Some patients with early-stage breast cancer may now be eligible for these shorter schedules in the United States.
  
  
• In another method, called partial breast irradiation (PBI), radiation is given to the tumor bed alone and not to the other areas of the breast where there is no evidence of cancer. Radiation is given twice a day for only one week using external-beam radiation, a temporary radiation catheter, or catheters implanted within the breast. Only some patients may be eligible for this type of radiation. While preliminary results have been promising, this technique is the subject of a large, nationwide clinical trial, and the results proving the safety and effectiveness compared with standard radiation are pending.

Radiation therapy can cause side effects, including fatigue, swelling, and skin changes. A small amount of the lung can be affected by the radiation, although the risk of pneumonitis, or a radiation-related pneumonia, is rare. In the past, with older equipment and techniques of radiation therapy, women treated for left-sided breast cancers had a small increase in the long-term risk of heart disease. Modern techniques are now able to spare most of the heart from radiation damage. While exposure to radiation is thought to be a risk factor of cancer after many years, less than one in 500 survivors will develop a different kind of cancer, other than a breast cancer, within the area that was treated. Clinical studies comparing lumpectomy and radiation therapy with mastectomy have not shown a difference in the number of patients developing or dying of other cancers within a 20-year time span.

For more information, read the Cancer.Net Feature: Understanding Radiation Therapy, the Cancer.Net Feature: Radiation Therapy-Your Personal Experience, and the Cancer.Net Feature: Side Effects of Radiation Therapy.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished. Rarely, long-term side effects may occur, such as heart damage, nerve damage, or secondary cancers, but studies have shown that these side effects do not shorten a woman's survival time.

Chemotherapy may be given orally (by mouth) or intravenously (injected into a vein) and is usually given in cycles. Chemotherapy generally does not require a hospital stay; it is given in an outpatient setting. Chemotherapy may be neoadjuvant therapy (given before surgery to shrink a large tumor) or adjuvant therapy (given after surgery to reduce the risk that the cancer returns). Chemotherapy may also be given at the time of a breast cancer recurrence. Patients in clinical trials may be offered new drugs or new combinations of existing drugs.

Different drugs are useful for different cancers, and research has shown that combinations of certain drugs are more effective than individual ones. The following drugs may be used to treat breast cancer:

• Cyclophosphamide (Cytoxan, Neosar)
  
  
• Methotrexate (multiple brand names)
  
  
• Fluorouracil (5-FU, Adrucil)
  
  
• Doxorubicin (Adriamycin, Rubex)
  
  
• Pegylated liposomal doxorubicin (DOXIL, Dox-SL, Evacet, LipoDox)
  
  
• Epirubicin (Ellence)
  
  
• Paclitaxel (Taxol)
  
  
• Docetaxel (Taxotere)
  
  
• Vinorelbine (Navelbine)
  
  
• Capecitabine (Xeloda)
  
  
• Protein bound paclitaxel (Abraxane)
  
  
• Gemcitabine (Gemzar)

Common combinations of drugs include the following:

• CMF (cyclophosphamide, methotrexate, and 5-FU)
  
  
• CAF (cyclophosphamide, doxorubicin, and 5-FU)
  
  
• CEF (cyclophosphamide, epirubicin, and 5-FU)
  
  
• EC (epirubicin and cyclophosphamide)
  
  
• AC (doxorubicin and cyclophosphamide)
  
  
• TAC (docetaxel, doxorubicin, and cyclophosphamide)
  
  
• AC followed by T (doxorubicin and cyclophosphamide, followed by paclitaxel)
  
  
• TC (docetaxel and cyclophosphamide)
  
  
• AT (doxorubicin and docetaxel; doxorubicin and paclitaxel)
  
  
• GT (gemcitabine and paclitaxel)
  
  
• Docetaxel and capecitabine

Some of these drugs may also be combined with trastuzumab, a targeted therapy (see below).

The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications you've been prescribed, their purpose, and their potential side effects or interactions. Learn more about your prescriptions through Cancer.Net's Drug Information Resources, which provides links to multiple drug databases.

Hormone therapy

Hormone therapy is useful to manage a tumor that tests positive for either estrogen or progesterone receptors. This type of tumor uses hormones to fuel its growth. Blocking the hormones usually limits the growth of the tumor.

If it is determined that the tumor is hormone receptor-positive (uses estrogen or progesterone to grow [see Diagnosis]), than hormone treatment may be used alone or along with chemotherapy. Examples of hormone therapy used as adjuvant therapy are tamoxifen, anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin).

Tamoxifen is the drug that researchers have studied the longest for use as a hormone therapy. It blocks estrogen from binding to breast cancer cells. It has been shown to be effective for reducing the risk of recurrence in the treated breast, the risk of developing cancer in the other breast, and the risk of developing cancer in women with no history of the disease but who are at higher than average risk for developing breast cancer. Current research shows that there is no benefit for taking tamoxifen longer than five years.

The side effects of tamoxifen include hot flashes, a small increased risk of uterine (endometrial) cancer and uterine sarcoma, and an increase in the risk of blood clots. Tamoxifen can be effective in both premenopausal and postmenopausal women.

In postmenopausal women who have an increased risk of developing breast cancer, raloxifene has shown to be another hormone therapy that is as effective as tamoxifen in preventing invasive breast cancer, but not as effective in preventing noninvasive cancers, such as DCIS. The side effects of raloxifene include a small risk of blood clots, leg and joint pain, hot flashes, pain during sexual intercourse, and vaginal dryness. Raloxifene has not been studied in premenopausal women, and it is not considered a substitute for tamoxifen for adjuvant therapy for women with hormone receptor-positive breast cancer. Raloxifene is not recommended for treatment of invasive breast cancer.

Aromatase inhibitors decrease the amount of estrogen in postmenopausal women by blocking the aromatase enzyme, which is needed to make estrogen. These drugs include anastrozole, letrozole, and exemestane. The side effects of aromatase inhibitors may include joint pain and an increased risk of fractures (broken bones). For more information, please read the ASCO Technology Assessment for Patients: Aromatase Inhibitors for Early Breast Cancer.

Targeted therapy

Several promising new breast cancer drugs work by stopping the action of abnormal proteins that cause cells to grow and divide out of control.

Monoclonal antibodies target proteins that are present in unusually large amounts in breast cancer cells.

• Trastuzumab is approved for both the treatment of advanced breast cancer and as an adjuvant therapy for early-stage breast cancer for tumors that have too much of the HER2/neu protein. Data presented at the 2005 American Society of Clinical Oncology Annual Meeting demonstrated an approximate 50% decrease in recurrence and an improvement in survival in women with early breast cancer with a HER2-positive breast cancer who received trastuzumab either with or after adjuvant chemotherapy. At this time, one year of trastuzumab is recommended. Patients receiving trastuzumab have a 4% risk of heart problems, and this risk is increased if a patient has other risk factors for heart disease. These heart problems do not always go away, but they are usually treatable with medication. Ongoing research is assessing how much trastuzumab is enough (from nine weeks up to two years).
  
  
• Bevacizumab (Avastin) is an antiangiogenic monoclonal antibody under study in clinical trials. Anti-angiogenesis agents block angiogenesis (the formation of new blood vessels), which is needed for tumor growth and metastasis. When combined with paclitaxel, bevacizumab appears to increase the response rate and length of response compared with paclitaxel alone in women whose breast cancer has spread.
  
  
• For women with HER2-positive breast cancer that no longer responds to trastuzumab, a new drug called lapatinib (Tykerb) may slow the growth of breast cancer when combined with capecitabine. The combination of lapatinib and capecitabine is approved for the treatment of women with advanced or metastatic HER2-positive breast cancer who have previously been treated with chemotherapy and trastuzumab.

Recurrent breast cancer

Breast cancer is called recurrent if the cancer has come back after it was first diagnosed and treated. It may come back in the breast (a local recurrence); in the chest wall; or in another part of the body, including distant organs (such as the lungs, liver, and bones).

Breast cancer may also spread to other organs such as the brain, the opposite breast, adrenal glands, spleen, and ovaries. If the tumor is metastatic (spread outside of the breast or local lymph nodes), the cancer is generally not curable. The goal of treatment for advanced disease is to achieve remission (temporary or permanent absence of disease) or slow the growth of the tumor. Some patients live years after a recurrence of breast cancer and may undergo many different treatments. With the advent of earlier detection methods and new therapies, breast cancer may be considered a chronic disease for some patients.

Generally, a recurrence is detected when a person has symptoms. Even though there are tests that may detect a metastatic recurrence before the onset of symptoms, research has shown that tests do not improve the response to treatments used for advanced disease, nor do they prolong life.

Once metastatic disease is detected, a woman may undergo surgery to remove the metastasis or receive chemotherapy, hormone therapy, radiation therapy, or targeted therapy (such as trastuzumab) to control it. Signs and symptoms depend on the site of the recurrence and may include:

• A lump under the arm or along the chest wall
  
  
• Bone pain or fractures, which may signal bone metastases
  
  
• Headaches or seizures, which may signal brain metastases
  
  
• Chronic coughing or trouble breathing, which may signal lung metastases

Other symptoms may be related to the location of metastasis and may include changes in vision, changes in energy levels, feeling ill, or extreme fatigue.

A biopsy of the recurrent site is often recommended to be certain of the diagnosis and to check for ER, PR, and HER2/neu status. For women with a recurrence within the breast after initial treatment with lumpectomy and radiation therapy, the treatment is mastectomy. For women with a recurrence of the chest wall after an initial mastectomy, radiation therapy to the chest wall and lymph nodes is the treatment. Often hormone therapy is used if possible. Chemotherapy and targeted therapies are also used in select cases. Radiation therapy and surgery may be used in certain situations in women with distant metastatic recurrences.

Treatment guides from ASCO for breast cancer include Aromatase Inhibitors for Early Breast Cancer, Bisphosphonates for Breast Cancer, Follow-Up Care for Breast Cancer, HER2 Testing for Breast Cancer, Sentinel Lymph Node Biopsy for Early-Stage Breast Cancer, and Breast Cancer Tumor Markers.

To learn about the terms used in this section, read the Cancer.Net Feature: Cancer Terms to Know: During Treatment.

For More Information

The National Comprehensive Cancer Network (NCCN) has a series of treatment guidelines that have been translated into patient-friendly language. In accordance with Cancer.Net's Linking Policy, please note that this link does not imply ASCO's endorsement of the content, but rather it is an effort to provide additional information that may be helpful to people living with cancer and their families. The NCCN treatment guide for breast cancer can be found at www.nccn.org.

Doctors and scientists are always looking for better ways to treat patients with breast cancer. A clinical trial is a way to test a new treatment in order to prove that it is safe, effective, and possibly better than a standard treatment. Patients who participate in clinical trials are among the first to receive new treatments, such as new chemotherapy, before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.

Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that this is the only way to make progress in treating breast cancer, such as finding new drugs. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with breast cancer.

To join a clinical trial, patients must complete a learning process known as informed consent. During informed consent, the doctor should list all of the patient's options, so that the person understands the standard treatment, and how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different from the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment. Learn more about clinical trials, including patient safety, phases of a clinical trial, deciding to participate in a clinical trial, questions to ask the research team, and links to find cancer clinical trials.

Cancer and cancer treatment can cause a variety of side effects; some are easily controlled and others require specialized care. Below are some of the side effects that are more common to breast cancer and its treatments. For more detailed information on managing these and other side effects of cancer and cancer treatment, visit the Cancer.Net Managing Side Effects section.

Anemia. Anemia is common in people with cancer, especially those receiving chemotherapy. Anemia is an abnormally low level of red blood cells (RBCs). RBCs contain hemoglobin (an iron protein) that carries oxygen to all parts of the body. If the level of RBCs is too low, parts of the body do not get enough oxygen and cannot work properly. Most people with anemia feel tired or weak. The fatigue (tiredness) associated with anemia can seriously affect quality of life and make it more difficult for patients to cope with cancer and treatment side effects.

Fatigue. Fatigue is extreme exhaustion or tiredness, and is the most common problem that people with cancer experience. More than half of patients experience fatigue during chemotherapy or radiation therapy, and up to 70% of patients with advanced cancer experience fatigue. Patients who feel fatigue often say that even a small effort, such as walking across a room, can seem like too much. Learn more about Coping With Cancer-Related Fatigue.

Fluid in the abdomen (ascites). Ascites is the buildup of fluid in the abdomen, in the area around the organs known as the peritoneal cavity. Ten percent of all ascites is caused by cancer and is called malignant ascites. Most cancer-related ascites appears in patients with cancers of the ovary, endometrium (lining of the uterus), breast, colon, gastrointestinal (GI) system, or pancreas. These cancers can cause fluid to build up in the body. People with ascites may experience weight gain, abdominal swelling, a sense of fullness or bloating, a sense of heaviness, indigestion, nausea and/or vomiting, changes to the navel, hemorrhoids (a condition that causes painful swelling near the anus), or ankle swelling.

Fluid in the arms or legs (lymphedema). Lymphedema is the abnormal buildup of lymph (fluid) in the series of channels and nodes that carry lymph through the body and help fight infection and disease. Lymphedema can develop immediately after cancer surgery or radiation therapy, or it can develop months or years later. The most common causes of lymphedema include surgery to remove the lymph nodes, especially for breast cancer, prostate cancer, or melanoma; radiation therapy to the lymph nodes; metastatic cancer; bacterial or fungal infection; injury to the lymph nodes; and other diseases involving the lymph system.

Fluid around the lungs (malignant pleural effusion). A pleural effusion is a condition characterized by extra fluid building up in the pleural space, the space between the edge of the lungs and the chest wall. A malignant pleural effusion is caused by cancer that grows in the pleural space. About half of patients with cancer develop a pleural effusion. More than 75% of patients with a malignant pleural effusion have lymphoma or cancers of the breast, lung, or ovary. The symptoms of a pleural effusion include dyspnea (shortness of breath), dry cough, pain, feeling of chest heaviness, inability to exercise, and malaise (feeling unwell).

Hair loss (alopecia). A potential side effect of radiation therapy and chemotherapy is hair loss. Radiation therapy and chemotherapy cause hair loss by damaging the hair follicles responsible for hair growth. Hair loss may occur throughout the body, including the head, face, arms, legs, underarms, and pubic area. The hair may fall out entirely, gradually, or in sections. In some cases, the hair will simply thin-sometimes unnoticeably-and may become duller and dryer. Losing one's hair can be a psychologically and emotionally challenging experience and can affect a patient's self-image and quality of life. However, the hair loss is usually temporary, and the hair often grows back.

Hypercalcemia. Hypercalcemia is an unusually high level of calcium in the blood. Hypercalcemia can be life threatening and is the most common metabolic disorder associated with cancer, occurring in 10% to 20% of patients with cancer. Patients with hypercalcemia may experience loss of appetite, nausea and/or vomiting; constipation and abdominal pain; increased thirst and frequent urination; fatigue, weakness, and muscle pain; changes in mental status, including confusion, disorientation, and difficulty thinking; and headaches. Severe hypercalcemia can be associated with kidney stones, irregular heartbeat or heart attack, and eventually loss of consciousness and coma.

Infection. An infection occurs when harmful bacteria, viruses, or fungi (such as yeast) invade the body and the immune system is not able to destroy them quickly enough. Patients with cancer are more likely to develop infections because both cancer and cancer treatments (especially chemotherapy and radiation therapy to the bones or extensive areas of the body) can weaken the immune system. Symptoms of infection include fever (temperature of 100.5°F or higher); chills or sweating; sore throat or sores in the mouth; abdominal pain; pain or burning when urinating or frequent urination; diarrhea or sores around the anus; cough or breathlessness; redness, swelling, or pain, especially around a cut or wound; and unusual vaginal discharge or itching.

Menopausal symptoms in women. Up to 40% of women experience menopausal symptoms because of breast cancer or its treatments. Menopausal symptoms may depend on the type of therapy and may include hot flashes; night sweats; vaginal dryness, itching, irritation, or discharge; painful sexual intercourse; difficulties with bladder control; depressed feelings; and insomnia. Premenopausal women receiving chemotherapy for breast cancer may undergo menopause at an earlier age than expected.

Mouth sores (mucositis). Mucositis is an inflammation of the inside of the mouth and throat, leading to painful ulcers and mouth sores. It occurs in up to 40% of patients receiving chemotherapy. Mucositis can be caused by chemotherapy directly, the reduced immunity brought on by chemotherapy, or radiation treatment to the head and neck area.

Nausea and vomiting. Vomiting, also called emesis or throwing up, is the act of expelling the contents of the stomach through the mouth. It is a natural way for the body to rid itself of harmful substances. Nausea is the urge to vomit. Nausea and vomiting are common in patients receiving chemotherapy for cancer and in some patients receiving radiation therapy. Many patients with cancer say they fear nausea and vomiting more than any other side effects of treatment. When it is minor and treated quickly, nausea and vomiting can be quite uncomfortable but cause no serious problems. Persistent vomiting can cause dehydration, electrolyte imbalance, weight loss, depression, and avoidance of chemotherapy.

Sexual dysfunction. Sexual dysfunction is common in all people, affecting up to 43% of women and 31% of men. It may be even more common in patients with cancer, because of treatments, the tumor, or stress. Many people, with or without cancer, find it intimidating to discuss sexual problems with their doctors. Sexual problems are most commonly caused by body changes from cancer surgery, chemotherapy or radiation therapy, hormone changes, fatigue, pain, nausea and/or vomiting, medications that reduce libido (desire for sex), fear of recurrence, stress, depression, and anxiety. Symptoms of sexual dysfunction generally fall into four categories: desire disorders, arousal disorders, orgasmic disorders, and pain disorders.

Skin problems. The skin is an organ system that contains many nerves. Because of this, skin problems can be very painful. Because the skin is on the outside of the body and visible to others, many patients find coping with skin problems especially difficult. Because the skin protects the inside of the body from infection, skin problems can often lead to other serious problems. As with other side effects, prevention or early treatment is best. In other cases, treatment and wound care can often improve pain and quality of life. Skin problems can have many different causes, including chemotherapy leaking out of the intravenous (IV) tube, which can cause pain or burning; peeling or burned skin caused by radiation therapy; or pressure ulcers (bed sores) caused by constant pressure on one area of the body.

Weight gain. Although it is more common to lose weight during cancer treatment, some patients with cancer gain weight. Slight increases in weight during cancer treatment are generally not problematic. However, significant weight gain may affect a patient's health and the ability to tolerate treatments. Chemotherapy, steroid medications, and hormone therapy can cause weight gain.

After treatment for breast cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years. The recommendations for breast cancer follow-up care usually include regular physical examinations and mammograms. Specific information can be found in the ASCO Patient Guide: Follow-up Care for Breast Cancer.

Breast cancer can come back in the breast or other areas of the body. The symptoms of a cancer recurrence include a new lump in the breast, under the arm, or along the chest wall; bone pain or fractures; headaches or seizures; chronic coughing or trouble breathing; extreme fatigue; and/or feeling ill. Talk with your doctor if you have these or other symptoms. The possibility of recurrence is a common concern among cancer survivors; learn more about Coping With Fear of Recurrence.

After surgery (mastectomy or lumpectomy) to treat breast cancer, the breast may be scarred and may have a different shape or size than before surgery. If lymph nodes were removed as part of the surgery or affected during treatment, lymphedema (swelling of the arm) may occur. Read the Cancer.Net Feature: After Treatment for Breast Cancer: Preventing Lymphedema (Updated), Cancer.Net Feature: After a Mastectomy: What to Know, Cancer.Net Feature: After Treatment for Breast Cancer: Breast Reconstruction, and Cancer.Net Feature: After Treatment for Breast Cancer: Choosing a Breast Prosthesis.

Some patients experience breathlessness, a dry cough, and/or chest pain two to three months after finishing radiation therapy because the treatment can cause swelling and fibrosis (hardening or thickening) of the lungs. These symptoms are usually temporary. Talk with your doctor if you develop any new symptoms after radiation therapy or if the side effects are not going away.

Women taking tamoxifen should have yearly pelvic exams, because this drug can increase the risk of uterine cancer. Tell your doctor or nurse if you notice any abnormal vaginal bleeding or other new symptoms. Women who are taking an aromatase inhibitor, such as anastrozole, exemestane, or letrozole, should have a bone density test before they start treatment and as recommended by their doctor, as these drugs may cause some bone weakness or bone loss.

Women recovering from breast cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight and diet and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create a safe exercise plan based upon your needs, physical abilities, and fitness level. Learn more about Healthy Living After Cancer.

To learn about the terms used in this section, read the Cancer.Net Feature: Cancer Terms to Know: After Treatment.

Research for breast cancer is ongoing. The following advances may still be under investigation in clinical trials and may not be approved or available at this time. Always discuss all diagnostic and treatment options with your doctor.

Improved surgery. New surgical methods that save tissue or prevent scarring are being tested in clinical trials. A skin-sparing mastectomy may result in less scarring than traditional surgery.

Partial breast radiation therapy. Partial breast radiation therapy is radiation therapy that is given directly to the tumor area, usually after a lumpectomy, instead of the entire breast, as is routinely done with standard radiation therapy. This treatment can be done with external-beam radiation therapy or internal radiation therapy. Internal radiation therapy is a way to deliver radiation directly to the tumor site. In this treatment, small radioactive pellets are placed in or near the site of the breast tumor within plastic catheters placed temporarily in the breast. Targeting the radiation to the tumor area more directly may shorten the amount of time that patients need to undergo radiation therapy. A large national clinical trial began in 2005 that compares the standard treatment of six weeks of conventional external-beam radiation therapy with a one-week treatment of partial breast radiation therapy.

Intensity-modulated radiation therapy (IMRT). IMRT is a more advanced way to deliver external-beam radiation therapy to the breast. The intensity of the radiation directed at the breast is varied to target the tumor more precisely, give a uniform distribution of radiation throughout the breast tissue, and avoid damaging healthy tissue than is possible with traditional radiation treatment. IMRT may reduce the dose to nearby important organs, such as the heart and lung, and reduce the risks of some immediate side effects, such as peeling of the skin during treatment. This can be especially important for women with medium to large breast sizes, who have been at greater risk for side effects such as peeling, compared with small-breasted women. IMRT also may help to reduce long-term effects on the breast tissue that were common with older radiation techniques such as hardness, swelling, or discoloration.

Chemotherapy, hormone therapy, and biologic therapy. New drugs and combinations of chemotherapy, hormone therapy, and biologic therapy are being studied in clinical trials.

Regular communication with your doctor is important in making informed decisions about your health care. Consider asking the following questions of your doctors:

Questions to ask your breast surgeon, before your first surgery

Are you board-certified?

Do you specialize in this type of surgery?

How many operations like the one I am considering have you performed?

Do I need any other tests before this surgery?

Can you tell me what stage the breast cancer is in? What does this mean?

Could I have a lumpectomy?

Do I need a mastectomy? If so, would you recommend an immediate breast reconstruction (plastic surgery)?

Should my lymph nodes in my underarm be removed?

What is a sentinel lymph node biopsy? What are the benefits and risks? Would you recommend it for me?

What is the risk of lymphedema with a sentinel lymph node biopsy? With axillary lymph node dissection?

Should I consider chemotherapy before surgery?

When do I need to make a decision about surgery?

What should I do to get ready for the operation? Do you have recommendations on how to help me relax before surgery?

What medications and supplements should I stop taking? Should I stop taking hormone replacement therapy? What about birth control pills?

How long will my surgery take?

Will you describe exactly what you will be doing during this operation, and why?

What type of anesthesia will I need for this operation?

Where will the scar be, and what will it look like?

What are the potential risks and side effects of this operation?

What can I do to ease side effects following surgery?

What can I expect regarding the operation?

• Will I need to be admitted to a hospital for this operation? If so, how long will I stay in the hospital?
  
  
• How long do I have to wait for my laboratory test results? Do I call you, or do you call me?
  
  
• Will a pathologist examine the tissue and write a report? Who will explain that report to me?
  
  
• What are the possible complications for this type of surgery? How would I know if there is a problem?
  
  
• How long will it take me to recover after the surgery?
  
  
• Will I have stitches, staples, and/or bandages?
  
  
• Will there be permanent effects from the surgery?
  
  
• Are there instructions or post-operative care pamphlets I can take home with me? When can I shower or bathe?
  
  
• Will I need to have surgical drains? What does this mean?
  
  
• When will I need to return for a follow-up appointment?

Questions to ask your breast surgeon, after your first surgery

What type of breast cancer do I have?

What is the size of the tumor?

What is the grade and stage of this disease? What does this mean?

Can you explain my pathology report (laboratory test results) to me?

Can I get a copy of my pathology report?

Was all of the cancer removed during the surgery?

Has the cancer spread to my lymph nodes or anywhere else in my body?

What is the hormone status of my tumor? What does this mean?

What is my HER-2 status? What does this mean?

Do I need additional surgery?

Do I need other treatment, such as chemotherapy or radiation therapy?

When do I need to make a decision about starting additional treatment?

Should I see other doctors? Can you give me referrals (names of doctors) to see?

Questions to ask your medical oncologist

What type of breast cancer do I have?

What is the size of my tumor?

What is the grade and stage of this disease? What does this mean?

What is the hormone status of my tumor? What does this mean?

What is my HER-2 status? What does this mean?

Do I need more tests to find out if there is cancer anywhere else in my body?

What is my prognosis?

What are my options for treatment?

What is chemotherapy? What is hormone (endocrine) therapy? What is biologic therapy? What is targeted therapy?

How will each treatment option benefit me? What are the risks?

What is the expected timeline for each treatment option?

Should I get a second opinion?

What clinical trials are available to me?

What can I do to get ready for this treatment?

What are the potential side effects of this treatment?

What can I do to ease side effects?

How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?

What lifestyle changes should I consider making during my treatment?

Will I lose my hair?

Could this treatment affect my fertility (ability to have children in the future)? Are there other treatments available that do not pose as high a risk to my fertility but are equally effective?

How does having reached (or not reached) menopause affect my treatment options?

Should I consider my family's history of breast cancer in making my decision about treatment?

Whom can I call if I have a problem or question about my treatment?

Whom can I contact for supportive and emotional help for me? For my family?

How will you determine if the cancer has come back after treatment?

After my treatment has ended, what will my follow-up care plan be?

• How often will I need to see a doctor?
  
  
• What tests will I need?
  
  
• How often will I need those tests?
  
  
• Can I get copies of my laboratory test results?

Questions to ask your radiation oncologist

What is radiation therapy?

What is the goal of this treatment? Is it to eliminate the cancer?

What are the chances that this treatment will prevent the cancer from coming back?

How often will I receive radiation therapy?

How much time will each treatment take?

Will each treatment be the same? Does the radiation dose or area treated change throughout the period of treatment?

What can I do to get ready for this treatment?

How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?

Will you describe what I will experience when I receive radiation therapy? Will it hurt or cause me discomfort during the treatment?

What are the potential side effects of this treatment? How can I ease side effects?

How will my skin be affected during radiation therapy? What skin products can I use each day?

Do I need to be concerned about sun exposure?

Should I avoid certain foods, vitamins, or supplements?

Should I avoid using deodorant or antiperspirant during treatment?

What are the possible long-term effects of this treatment?

If I decide to have reconstructive surgery, how would that affect my treatment plan?

Will this treatment affect my fertility?

Are there special services for patients receiving radiation therapy, such as certain parking spaces or parking rates?

Questions to ask your plastic surgeon

Are you board-certified?

Is breast reconstruction your specialty?

How many breast reconstruction surgeries do you perform in a year?

Now that you have examined me, am I a good candidate for reconstruction?

What types of breast reconstruction options do I have?

What are the advantages and disadvantages of each type?

When can I have my reconstruction?

Will I need to coordinate this with my breast surgeon?

If I have radiation therapy, does that change my options for reconstruction?

What are tissue expanders, and will I need them?

What type of implants do you use? Do you use saline and/or silicone?

What are the advantages and disadvantages of each?

Which type of implants do you recommend, and why? What size?

If you use tissue from another part of my body to rebuild my breast(s), where do you recommend it be taken from, and why?

If I have a mastectomy with implant reconstruction, can I also have a nipple reconstruction? If so, when?

What are the costs involved with breast reconstruction? What is covered by my insurance?

How long will the surgery take?

What do I need to do to prepare for the surgery?

What type of anesthesia will I need for this operation?

What can I expect after the operation?

• How long will I stay in the hospital?
  
  
• What are the possible complications for this type of surgery?
  
  
• How long will it take me to recover?
  
  
• When can I resume my normal activities, including exercise?
  
  
• Will I need to have surgical drains? What does this mean?
  
  
• Will I have stitches, staples, and/or bandages?
  
  
• Will there be a scar or other permanent effects from the surgery?
  
  
• Are there instructions or post-operative care pamphlets I can take home with me?
  
  
• When will I need to return for a follow-up appointment?

What type of results can I expect?

If the reconstruction is on one side only, will it match my other breast's size and shape?

How will the reconstructed breast feel to the touch?

What type of sensation (feeling) will the reconstructed breast have?

What changes to the reconstructed breast can I expect over time?

Will I need to have surgery again in the future (for example, to replace implants over time)?

What can I expect if my weight changes?

What if I become pregnant in the future?

Questions to ask your fertility specialist

People diagnosed with breast cancer may wish to consult with a fertility specialist, in addition to the doctors listed above, prior to treatment if they are concerned about their ability to have children in the future.

How often do you advise people with cancer?

Will this cancer treatment affect my fertility now or in the future?

If so, what are my options to preserve my fertility?

What clinical trials are open to me?

Will attempting to preserve fertility decrease the effectiveness of my cancer treatments (for example, is there a risk of hormones used in this treatment affecting my type of breast cancer, or is there a risk in delaying cancer treatment in order to have this treatment)?

How long should I wait after cancer treatment before trying to have a child?

Can I become pregnant while receiving chemotherapy or radiation therapy? What happens if I become pregnant during treatment? Is there a risk of birth defects and/or harm to the fetus and/or to me?

What are the costs involved with my options to preserve fertility? What is covered by my insurance?

American Society of Breast Disease
P.O. Box 140186
Dallas, TX  75214
Phone: 214-368-6836
www.asbd.org

Breast Cancer Network of Strength
212 W Van Buren, Ste. 1000
Chicago, IL  60607
Toll Free: 800-221-2141 (English)
Toll Free: 800-986-9505 (Spanish)
Phone: 312-986-8338
www.networkofstrength.org

Breastcancer.org
111 Forrest Ave., 1R
Narberth, PA 19702
www.breastcancer.org

Breastlink
23430 Hawthorne Blvd., Ste 340
Torrance, CA  90505
Phone: 310-791-6610
www.breastlink.com

Fertile Hope
65 Broadway, Ste. 603
New York, NY  10006
Toll Free: 888-994-HOPE (888-994-4673)
www.fertilehope.org

FORCE: Facing Our Risk of Cancer Empowered
16057 Tampa Palms Blvd. W, PMB 373
Tampa, FL  33647
Toll Free Helpline: 866-824-RISK (7475)
Toll Free: 866-288-7475
Phone: 954-255-8732
www.facingourrisk.org

HER2 Support Group
6973 Mimosa Dr.
Carlsbad, CA  92009
Phone: 760-602-9178
www.her2support.org

Inflammatory Breast Cancer Research Foundation
321 High School Rd. NE, Ste. D3 #149
Bainbridge Island, WA  98110
Toll Free: 877-STOP-IBC (877-786-7422)
www.ibcresearch.org

Living Beyond Breast Cancer
10 E Athens Ave., Ste. 204
Ardmore, PA  19003
Toll Free: 888-753-LBBC (888-753-5222)
Phone: 610-645-4567
www.lbbc.org

Mothers Supporting Daughters with Breast Cancer
25235 Fox Chase Dr.
Chestertown, MD  21620
Phone: 410-778-1982
www.mothersdaughters.org

National Breast Cancer Coalition
1101 17th St., NW, Ste. 1300
Washington, DC  20036
Toll Free: 800-622-2838
Phone: 202-296-7477
www.stopbreastcancer.org

National Cancer Institute
Public Inquiries Office
Bldg. 31, Rm. 10A31
31 Center Dr., MSC 2580
Bethesda, MD  20892
Toll Free: 800-4-CANCER
Phone: 301-435-3848
TTY: 800-332-8615
www.cancer.gov

National Comprehensive Cancer Network
500 Old York Rd., Ste. 250
Jenkintown, PA  19046
Phone: 215-690-0300
www.nccn.org

National Lymphedema Network
Latham Square
1611 Telegraph Ave., Ste. 1111
Oakland, CA  94612
Toll Free: 800-541-3259
Phone: 510-208-3200
www.lymphnet.org

Nueva Vida, Inc.
2000 P St., NW, Ste. 740
Washington, DC  20036
Phone: 202-223-9100
www.nueva-vida.org

SHARE: Self-help for Women with Breast or Ovarian Cancer
1501 Broadway, Ste. 704A
New York, NY  10036
Toll Free: 866-891-2392
Phone: 212-719-0364