Breast Cancer

Topic Overview

Is this topic for you?

This topic is for people who have been diagnosed with breast cancer for the first time. If you are looking for information on breast cancer that has spread or come back after treatment, see the topic Breast Cancer, Metastatic or Recurrent.

What is breast cancer?

Breast cancer occurs when abnormal cells grow out of control in one or both breasts. They can invade nearby tissues and form a mass, called a malignant tumor. The cancer cells can spread (metastasize) to the lymph nodes and other parts of the body.

Breast cancer is many women’s worst fear. But experts have made great progress in treating cancer. If it is found early, breast cancer can often be cured, and it is not always necessary to remove the breast.

What causes breast cancer?

Doctors do not know exactly what causes breast cancer. But some things are known to increase the chance that you will get it. These are called risk factors. The main risk factors for breast cancer include:¹

• Aging. Breast cancer is much more common in older women than in younger women. Your breast cancer risk increases as you age.²
• Family history of breast cancer . You have a higher risk if a close family member, especially your mother or sister, has had breast cancer.
• Female hormones. Using hormone therapy after menopause raises your risk. This includes estrogen-progestin and estrogen-testosterone.^{1, 3} Using estrogen by itself may slightly raise breast cancer risk.¹ And your risk is slightly higher if you started your period before age 12 or started menopause after age 55. The years when you have a menstrual cycle are your high-estrogen years. Experts think that the longer you have higher estrogen, the more risk you have for breast cancer.⁴
• Gene changes. Women who inherit certain genes called BRCA1 and BRCA2 are more likely to have breast cancer.

Some other things are known to increase your risk, such as having extra body fat, being inactive, or drinking alcohol (these lead to higher levels of estrogen in the body).^{4, 5}

But many women who have risk factors do not get breast cancer. And many women who get breast cancer do not have any known risk factors.

What are the symptoms?

Breast cancer can cause:

• A change in the way the breast feels. The most common symptom is a painless lump or thickening in the breast or underarm.
• A change in the way the breast looks. The skin on the breast may dimple or look like an orange peel. There may be a change in the size or shape of the breast.
• A change in the nipple. It may turn in. The skin around it may look scaly.
• A clear or bloody fluid that comes out of the nipple.

See your doctor right away if you notice any of these changes.

Many people think that only women get breast cancer. But about 1 in every 100 cases of breast cancer occurs in men. So any man who has a breast lump should be checked.^{6, 7}

How is breast cancer diagnosed?

During a regular physical exam, your doctor can check your breasts to look for lumps or changes. Depending on your age and risk factors, the doctor may advise you to have a mammogram, which is an X-ray of the breast. A mammogram can often find a lump that is too small to be felt. Sometimes a woman finds a lump during a breast self-exam.

If you or your doctor finds a lump or other change, the doctor will want to take a sample of the cells in your breast. This is called a biopsy. Sometimes the doctor will put a needle into the lump to take out some fluid or tissue (needle biopsy). In other cases, a surgeon may take out the whole lump through a small cut in your breast. The results of the biopsy help your doctor know if you have cancer and what type of cancer it is.

You may have other tests to find out the stage of the cancer. The stage is a way for doctors to describe how far the cancer has spread. Your treatment choices will be based partly on the type and stage of the cancer.

How is it treated?

Most people who have breast cancer have surgery to remove the cancer. The surgeon may also take out some or all of the lymph nodes under your arm to find out if the cancer has spread to this area. After surgery, you may have radiation therapy to destroy cancer cells. You may also get chemotherapy or hormone therapy. These are powerful medicines that travel through your body to kill cancer cells. You might have radiation, chemotherapy, or hormone therapy before surgery to help shrink the cancer.

Depending on the stage of your cancer, you may have a choice of:

• Surgery to remove just the cancer from the breast (breast-conserving surgery, or lumpectomy). You will need to have several weeks of radiation after surgery.
• Surgery to remove the breast (mastectomy). If you choose mastectomy, you can have an operation to make a new breast. This is called breast reconstruction. Sometimes radiation is not needed after a mastectomy.

In years past, having breast cancer meant that you would have to have your breast removed. In many cases, this is no longer true. Studies now show that for early-stage breast cancer, breast-conserving surgery followed by radiation therapy is as good as mastectomy.¹

You and your doctor will decide which mix of treatments is right for you based on many factors. These include facts about your cancer as well as your family history, other health problems, and your feelings about keeping your breast. Learn all you can about breast cancer and its treatment so you can make the choices that are right for you.

Treatments for breast cancer can cause side effects. Your doctor can let you know what problems to expect and help you find ways to manage them.

Finding out that you have breast cancer can cause a range of feelings, from sadness and fear to anger and despair. If your emotions are making it hard for you to move ahead, be sure to tell your doctor. You may be able to get counseling or find a support group. Talking with other people who have faced the same choices can be a big help.

Can breast cancer be prevented?

You cannot control some things that put you at risk for breast cancer, such as your sex and age. But you can change others. To stay as healthy as you can:

• Eat a healthy diet with lots of fruits, vegetables, and whole grains.
• Make exercise a routine part of your life.
• Stay at a healthy weight. Getting regular exercise and watching what you eat can help.
• If you drink alcohol, limit the amount. After menopause, even having one drink a day or less may increase the risk for breast cancer.

Still, there is no sure way to prevent breast cancer, so it is very important to have regular exams and mammograms. Discuss your risk factors with your doctor to find out how often you should have a mammogram.

If you have a strong family history of breast cancer, ask your doctor about genetic testing. A blood test can check for changes in the BRCA genes that may increase your chance of getting breast cancer.

Frequently Asked Questions

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Cause

The exact cause of breast cancer is not known. Female hormones and increasing age play a part. The chances that you will develop breast cancer increase as you age. In the United States, about 1 in every 8 women who live to be 80 will have been diagnosed with breast cancer at some point in her life.²

Family history also plays a role in the development of breast cancer. You are more likely to have breast cancer if your mother, father, or sister has breast cancer. Also, women who carry certain genes called BRCA1 and BRCA2 are more likely to have breast cancer. If you have a strong family history of breast or ovarian cancer, you may want to be tested for these genes. People who inherit specific changes, or mutations, in one or both of these genes have a greater risk of developing breast cancer.

Studies show that menopausal women who take hormone therapy with estrogen and progestin have an increased risk of breast cancer. Women who take estrogen alone may have a slightly increased risk.^{1, 8}

Many people believe that only women have breast cancer. But, although rare, about 1% of all breast cancer occurs in men. Most men who have breast cancer are older than 65, but it can appear in younger men. For this reason, any breast lump in an adult man is considered abnormal.⁷

Symptoms

The first sign of breast cancer is often a painless lump. But early breast cancer is often found on a mammogram before a lump can be felt.

Other symptoms of breast cancer may not appear until the cancer is more advanced. These include:

• A thickening in the breast or armpit.
• A change in the size or shape of the breast.
• Changes in the skin of the breast, such as a dimple or skin that looks like an orange peel.
• A change in the nipple, such as scaling of the skin or a nipple that turns in.
• A green or bloody fluid that comes from the nipple.
• A change in the color or feel of the skin around the nipple (areola).

About 1% of breast cancer occurs in men. Although most men diagnosed with breast cancer are older than 65, the disease can appear in younger men. For this reason, any breast lump in an adult male is considered abnormal.⁷

Inflammatory breast cancer is a specific type of breast cancer that involves the skin of the breast. It occurs when breast cancer cells form "nests" and block the lymphatic drainage from the skin of the breast. Symptoms include redness, tenderness, and warmth. Thickening of the skin of the breast (an orange-peel appearance), rapid breast enlargement, and ridging of the skin of the breast may also be present. Some women may also develop a lump in the breast. For more information, see the topic Inflammatory Breast Cancer.

What Happens

Breast cancer occurs when cells in the breast grow abnormally. As the breast cancer grows, it can spread to nearby tissues and lymph nodes . Advanced breast cancer can affect the bones, liver, and brain. Fortunately, when found at an early stage, breast cancer is highly curable.

Your doctor will learn more about how your breast cancer may behave when the cancer cells are examined under the microscope. This is called classification. It tells your doctor how rapidly the cancer cells are growing and dividing and where they may have started in the breast tissue. Tests for hormone receptors and other markers are also done. All of this information will help you and your doctor make decisions about treatment.

The stage indicates how far the cancer has spread within the breast, to nearby tissues, and to other organs. Your doctor will determine the stage of your breast cancer by gathering information from other tests, such as axillary lymph node surgery, blood tests, bone scans, and X-rays. The stage of your cancer is one of the most important pieces of information that will help guide your treatment options.

What Increases Your Risk

Although the exact cause of breast cancer is not known, most experts agree that there are several factors that increase your risk of breast cancer.

Top risk factors linked to breast cancer

Aging. Your risk of breast cancer increases as you get older. By age group, breast cancer is diagnosed in:²

• 4 out of 1,000 women in their 30s.
• 15 out of 1,000 women in their 40s.
• 26 out of 1,000 women in their 50s.
• 37 out of 1,000 women in their 60s.

Being female. Although breast cancer can occur in men, most breast cancer is found in women.

Conditions that increase the risk of developing breast cancer

Personal history of breast cancer. Women who have had breast cancer in one breast have an increased chance of having another breast cancer. The breast cancer can come back in the same breast, in the opposite breast, or in other areas of the body, such as the lungs, liver, brain, or bones.

Family history. A woman's risk of breast cancer increases if her mother, sister, daughter, or two or more other close relatives, such as cousins, have a history of breast cancer, especially if they were diagnosed with breast cancer before age 50.

• Women who inherit specific changes (genetic mutations) in the BRCA1 and BRCA2 genes are much more likely to have breast cancer. They are also more likely to have colon or ovarian cancer. But most women who have a family history of breast cancer do not have changes in BRCA genes.
• Mutations in the BRCA1 and BRCA2 genes are more common in certain ethnic groups, such as Ashkenazi Jews.⁹
• Genetic tests are available to determine whether you have the genetic mutations long before any cancer appears. In families where many women have had breast or ovarian cancer, genetic testing can show whether a woman has specific genetic changes known to greatly increase the risk of breast cancer. Doctors may suggest ways to try to prevent or delay breast cancer or to improve the detection of breast cancer in women who have the genetic mutations. For more information, see:

  Should I have a gene test for breast cancer?

Breast changes. Women who have atypical hyperplasia, ductal carcinoma in situ (DCIS), or lobular carcinoma in situ (LCIS) or who have had two or more breast biopsies for other noncancerous conditions are more likely to have breast cancer.

Other factors that increase the risk of breast cancer

Race. In the United States, breast cancer occurs more frequently in white women than in black, Hispanic, or Asian women. But black women are more likely to get breast cancer at a younger age and are also more likely to die of breast cancer.¹⁰ This may be linked in part to genetic differences—an aggressive type of breast cancer called basal-like tumor seems most likely to affect young African-American women. Lower survival rates among black women may also be linked to lower quality health care.¹¹

Radiation therapy. Women whose breasts were exposed to significant amounts of radiation at a young age, especially those who were treated for Hodgkin's lymphoma, have an increased risk for developing breast cancer. Studies show that the younger a woman was when she received her treatment, the higher her risk for developing breast cancer later in life.¹⁰

Late or no childbearing. Women who had their first child after the age of 30 have a greater chance of developing breast cancer than women who had their children at a younger age. Women who never had children have an increased risk for developing breast cancer.

Not breast-feeding. Women who don't breast-feed have a higher risk of breast cancer than those who breast-feed. The more months of breast-feeding, the lower the breast cancer risk.

Hormones. Female hormones play a part in some types of breast cancer.

• The use of hormone therapy after menopause for more than 4 years causes an increased risk of developing breast cancer. This increased risk occurs with current use of hormones and returns to normal over time after hormones are stopped.¹
• Beginning menstruation before age 12 and beginning menopause later than age 55 increase a woman's risk of breast cancer. The years when you have a menstrual cycle are your high-estrogen years. Experts think that the longer you have higher estrogen, the more risk you have for breast cancer.⁴
• Having extra body fat and drinking alcohol both lead to higher levels of estrogen in the body. Especially after menopause, when your estrogen levels are naturally low, this raises your breast cancer risk.⁴

For more information about your personal risk level, go to www.cancer.gov/bcrisktool.

When To Call a Doctor

The most common symptom of breast cancer is a painless lump. But, early breast cancer is often found on a mammogram before a lump can be felt. Other breast problems that need to be evaluated by a doctor include:

• A thickening in the breast or armpit.
• A change in the size or shape of the breast.
• Changes in the skin of the breast, such as a dimple or skin that looks like an orange peel.
• A change in the nipple, such as scaling of the skin, a nipple that turns in, or discharge or bleeding.
• A change in the color or feel of the skin around the nipple.

Any breast lump in an adult male is considered abnormal and needs to be evaluated by a doctor.^{6, 7}

Watchful Waiting

If you notice any changes in your breasts, call your doctor to arrange for an evaluation.

Who To See

Health professionals who can perform a breast exam include a:

• Family medicine doctor.
• General practitioner.
• Gynecologist.
• Internist.
• General surgeon or a surgeon who specializes in diseases of the breast.
• Nurse practitioner.
• Physician assistant.

Mammograms are usually read by radiologists.

You may see a general surgeon, a breast surgeon, or a radiologist if further evaluation of a breast problem is needed.

Breast cancer is treated by surgeons, medical oncologists, and radiation oncologists.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

Screening tests

The earlier breast cancer is found, the more easily and successfully it can be treated. The most common methods for detecting breast cancer include:

• Mammogram. A mammogram is an X-ray of the breast. It can often find tumors that are too small for you or your doctor to feel. Your doctor may suggest that you have a screening mammogram, especially if you have any risk factors for breast cancer.
• Clinical breast exam (CBE). During a clinical breast exam, your doctor will carefully feel your breasts and under your arms to check for lumps or other unusual changes.
• Magnetic resonance imaging (MRI) of the breast. MRI is a test that uses a magnetic field and pulses of radio wave energy to provide pictures of the inside of the breast. It may be more sensitive than a mammogram for finding breast cancer in women who have a strong family history of breast cancer. But MRI also finds small irregularities that can lead to further testing but turn out to not be breast cancer. MRI is also more expensive and not as readily available as mammography.

Talk to your doctor about MRI if you have risk factors for breast cancer. These can include a positive test for the BRCA1 or BRCA2 gene or having two or more close family members who have had breast cancer before age 50. For more information about your risk level, go to www.cancer.gov/bcrisktool.

The type and frequency of breast cancer screening that is best for you changes as you age.

A breast self-exam (BSE) is a simple procedure to help you detect breast lumps. It is a good way for you to learn what your breasts normally look and feel like. When you know what’s normal for you, you're better able to notice changes and know when to get help early instead of waiting for your next checkup. A breast self-exam is a tool that you can use on a regular basis, but it is not a substitute for a mammogram or a clinical breast exam. This is because large studies have shown that, on average, BSE alone does not lead to earlier diagnosis.¹² Nor does it reduce the number of deaths from breast cancer.¹³

Diagnostic tests

If your doctor thinks that you have breast cancer, you may have other tests, including:

• A mammogram, if you have not already had one.
• An ultrasound. You may have an ultrasound of the breast if a lump is found during a clinical breast exam or on a mammogram. Breast ultrasound is often used to distinguish between solid lumps and fluid-filled (cystic) lumps.
• An MRI of the breast, which is sometimes used to get more information about a breast lump or to evaluate problems in women who have breast implants. MRI of the breast may be most useful for very high-risk women, such as those who test positive for the BRCA1 or BRCA2 gene or have two or more close family members who have had breast cancer before age 50.¹⁴ MRI may also be used to evaluate the opposite breast in women diagnosed with breast cancer.¹⁵
• A breast biopsy. If a lump is found in your breast, your doctor will need to remove a small sample of the lump (biopsy) and look at it under a microscope to see whether any cancer cells are present. A needle biopsy is done by inserting a needle into the breast and removing some of the tissue. Tests that may be performed on any breast cancer cells that are found include:
  • Estrogen and progesterone receptor status. The hormones estrogen and progesterone stimulate the growth of normal breast cells, as well as some breast cancers. Hormone receptor status is an important piece of information that will help you and your doctor plan treatment.
  • HER-2 receptor status. HER-2/neu is a protein that regulates the growth of some breast cancer cells. About 25% of women with breast cancer have too much (overexpression) of this growth-promoting protein.
• A lymph node biopsy to see whether breast cancer cells have spread to the axillary lymph nodes under the arm. The two methods used are:
  • Surgery to take a sample of just one or two of the lymph nodes that are most likely to contain cancer cells. This surgery, called sentinel node biopsy, is now the standard way of checking the lymph nodes. Studies have shown that sentinel lymph node biopsy is as accurate as axillary lymph node dissection for staging breast cancer. Sentinel lymph node biopsy is less likely than axillary lymph node dissection to impair arm mobility, cause pain, or result in problems with swelling of the arm and hand (lymphedema).^{16, 17}
  • Surgery to remove most of the lymph nodes in the underarm. This is called an axillary lymph node biopsy.
• A complete blood count (CBC) to provide important information about the kinds and numbers of cells in your blood, including red blood cells, white blood cells, and platelets.
• A chemistry screen, to measure the levels of several substances (such as those involved in liver functions) in your blood.
• A chest X-ray, to provide a picture of organs and structures within your chest, including your heart and lungs, your blood vessels, and the thin sheet of muscle just below your lungs (diaphragm).

Tests if your doctor suspects that breast cancer has spread

If your doctor thinks that breast cancer may have spread to other organs in your body (metastasized), he or she may order additional testing, including a:

• CT scan to provide detailed pictures of the organs and structures in your chest, abdomen, and pelvis.
• Bone scan to detect cancer that has spread (metastasized) to the bones.
• CT scan or MRI of the brain to provide detailed pictures of your brain and to check for cancer that may have spread to your brain.

What to think about

If you have had breast cancer in one breast, you have an increased risk for developing breast cancer again. Breast cancer can come back in the same breast, on the chest wall, in your other breast, or somewhere else in your body (metastatic or recurrent breast cancer). To be sure that the cancer has not returned, you will have regular checkups that include physical exams and mammograms.

If you find any unusual changes in the treated area or in your other breast, or if you have swollen lymph glands or bone pain, call your doctor to discuss these changes. For more information, see the topic Breast Cancer, Metastatic or Recurrent.

Early detection

Early detection is an important factor in the success of breast cancer treatment. The earlier breast cancer is found, the more easily and successfully it can be treated. The three methods commonly used for early detection are:

• Mammogram. A mammogram is an X-ray of the breast that can often find tumors that are too small for you or your doctor to feel. Your doctor may suggest that you have a screening mammogram if you are older than 40, especially if you have any risk factors for breast cancer. Screening mammograms are most useful after age 50, but most experts recommend starting screening at age 40.
• Clinical breast exam (CBE). During a clinical breast exam, your doctor will carefully feel your breasts and under your arms to check for lumps or other unusual changes.
• Breast self-exam (BSE). A breast self-exam is a simple procedure to help you detect breast lumps. Do not use BSE in place of clinical breast exam and mammography. Studies have shown that BSE does not help find more early breast cancers.¹² It also does not reduce the number of deaths from breast cancer.¹³ But it does help familiarize you with your normal breast tissue. This may help you identify any new or unusual changes in your breasts.¹⁸

MRI of the breast may be most useful for very high-risk women, such as those who test positive for the BRCA1 or BRCA2 gene or have two or more close family members who have had breast cancer before age 50.¹⁴ MRI may also be used to evaluate the opposite breast in women diagnosed with breast cancer.¹⁵

The type and frequency of breast cancer screening that is best for you changes as you age.

Treatment Overview

Breast cancer is usually treated with surgery, medicine, and radiation therapy. Because of improved screening methods, diagnosis at an early stage, and improved treatment techniques, the number of deaths from breast cancer has been steadily declining over the past few years. Decisions about how to treat breast cancer are based on a combination of factors that include specific information about the cancer, your preferences, and your health.

When making decisions about treatment for your breast cancer, you and your doctor will consider:

• The size and location of your breast cancer (stage).
• How aggressive the breast cancer is.
• Whether your breast cancer has receptors to the hormones estrogen and progesterone, called estrogen receptor/progesterone receptor (ER/PR) status.
• Whether your breast cancer cells contain human epidermal growth factor (HER-2/neu).
• Whether your breast cancer has spread to the lymph nodes in your underarm area (axilla).

You and your doctor will also consider your personal preferences and health when developing a treatment plan for you. This will include:

• Your feelings about keeping your breast.
• Your personal and family history of breast cancer.
• Your age and whether you have other serious health problems.

Most people with breast cancer have surgery to remove the cancer from the breast. Some or all of the lymph nodes under the arm are also usually removed to find out whether the breast cancer has spread to this area.

Even if your doctor removes all the cancer that can be seen at the time of your surgery, you may be treated with radiation therapy. Chemotherapy or hormone therapy may also be recommended to make sure that the breast cancer cells have been destroyed. You may also be given chemotherapy or hormone therapy to shrink your breast cancer before surgery. This is called neoadjuvant therapy.

Initial treatment

Initial treatment of breast cancer may include:

• Surgery to remove the cancer. This may be done by removing the whole breast (mastectomy) or just the part of the breast that contains the breast cancer (breast-conserving surgery, or lumpectomy). Some of the lymph nodes under the arm will also be removed using either axillary lymph node dissection or sentinel node biopsy.
• Radiation therapy, which is the use of high-dose X-rays to destroy cancer cells and shrink tumors.
• Chemotherapy, which is the use of medicine to destroy cancer cells. Chemotherapy is called a systemic treatment, because the medicines enter the bloodstream, travel through the body, and can destroy cancer cells outside the target area.
• Hormone therapy with tamoxifen or an aromatase inhibitor, to change the way hormones in the body cause cancer growth.
• Treatment with trastuzumab (Herceptin) if your breast cancer tests positive for human epidermal growth factor (HER-2/neu).

What type of surgery should I have to treat early-stage breast cancer?

Should I use chemotherapy for early-stage breast cancer?

Treatment for women over 70

If you are older than 70, you may be a good candidate for having limited treatment and skipping lymph node biopsy or radiation.¹⁹ This depends on your health and what type of breast cancer you have.

Coping with your diagnosis

The diagnosis of breast cancer is devastating and scary. Most women will experience some denial, anger, and grief. There is no "normal" or "right" way to react to a diagnosis of cancer. There are many steps you can take to help with your emotional reaction to breast cancer. You may find that talking with family and friends helps you with your emotions. Some women find that spending time alone is what they need.

If your reaction interferes with your ability to make decisions about your health, it is important to talk with your doctor. Your cancer treatment center may offer psychological or financial services. You may also contact your local chapter of the American Cancer Society to help you find a support group. Talking with other people who may have had similar feelings can be very helpful.²⁰

Nausea and vomiting

One of the biggest concerns about treatment for cancer is managing nausea and vomiting from chemotherapy. Depending on the type of chemotherapy, you may only need home treatment to reduce mild nausea. But for certain types of chemotherapy, it's best to take prescription medicine for nausea and vomiting. In some cases, it's best to take it before the first dose of chemotherapy. Everyone is different. Work with your doctor to develop a plan that works for you.

For more ways to help manage side effects caused by breast cancer or breast cancer treatment, see the Home Treatment section of this topic.

Ongoing treatment

After the initial treatment for breast cancer, you may see your family doctor, general practitioner, medical oncologist, radiation oncologist, or surgeon at regularly scheduled intervals, depending on your individual situation. The length of time between visits will gradually lengthen until at 5 years, if no new problems develop, you are seeing your doctor once each year. As part of your follow-up, you may have:

• Physical exams. The frequency of your physical exams depends on your general health and the type of breast cancer you have. In general, you will see your doctor every 3 to 6 months for 3 years and then every 6 months until 5 years have passed since your diagnosis of breast cancer. You may see your doctor once a year at this point.
• Mammograms to screen for breast cancer and investigate lumps that can be felt during a breast exam.

After treatment for breast cancer, it is important to do regular self-exams. This may help you detect signs of recurrence. Early signs of recurrence may appear in the incision area itself, the opposite breast, under your arm, or in the area above the collarbone.

If new problems develop, you may have additional tests, such as blood tests, bone scans, chest X-rays, CT scans, or MRI tests.

If your breast cancer cells test positive for estrogen and progesterone receptors (ER/PR+), any remaining cancer cells may grow because of estrogen in your body. Medicine such as an aromatase inhibitor (such as Arimidex, Aromasin, or Femara), or tamoxifen (Nolvadex) may be a good treatment option. These hormone therapies block estrogen's effect on the cancer cells.

Studies show that an aromatase inhibitor works even better than tamoxifen in postmenopausal women who are also estrogen receptor-positive (ER+).^{21, 22, 23, 24} For women who have taken tamoxifen for a few years, switching to an aromatase inhibitor improves their chances of successful treatment.²⁵ Talk with your doctor about the risks and benefits of these medicines if your breast cancer is ER/PR+.

Treatment if the condition gets worse

For information about the treatment of metastatic or recurrent breast cancer, see the topic Breast Cancer, Metastatic or Recurrent.

What to Think About

Even if your doctor removes all the cancer that can be seen at the time of the operation, you may need additional treatment. Radiation therapy, chemotherapy, hormone therapy, or a combination of the three therapies may be used after surgery to try to destroy any cancer cells that may be left in your body. This is called adjuvant therapy and is used to reduce the chances that your breast cancer will come back. Talk with your doctor about the risks and benefits of each type of treatment. Your personal preferences and considerations are important when choosing a treatment that is right for you.

Should I use chemotherapy for early-stage breast cancer?

You may also make decisions about using chemotherapy or hormone therapy to shrink your breast cancer before surgery (neoadjuvant therapy). Talk with your doctor about the risks and benefits of each type of treatment.

The likelihood that your breast cancer will return after treatment depends on a number of factors, including the size and grade of your breast cancer, whether you had breast cancer cells in your lymph nodes, and how many lymph nodes were involved with breast cancer.

Prevention

You cannot control some things that put you at risk for breast cancer, such as your age and being female. But you can make personal choices that lower your risk of breast cancer. If you are at high risk for getting breast cancer, your doctor may also offer you certain medical treatments that can help prevent breast cancer.

Female hormones

Hormones change the way cells within the breast grow and divide. The years when you have a menstrual cycle are your high-estrogen years. Experts think that the longer you have higher estrogen, the more risk you have for breast cancer.⁴ This includes taking hormones after menopause.^{1, 26}

• Avoid long-term, high-dose hormones after menopause. If you use hormone therapy for menopause symptoms, use a low dose for as short a time as possible. This includes estrogen-progestin and estrogen-testosterone.^{1, 3} Using estrogen by itself may slightly raise breast cancer risk.¹
• Breast-feed. Breast-feeding may lower your breast cancer risk. The benefit appears to be greatest in women who breast-fed for longer than 12 months or who breast-fed several children.²⁷
• Strive for a healthy weight. Extra fat cells make extra estrogen, which raises your breast cancer risk.⁴ Getting regular exercise and watching what you eat can help.

Having a full-term pregnancy before age 30 also lowers your breast cancer risk.¹⁰

Healthy food and exercise

• Eat a healthy diet with plenty of fruits, vegetables, and whole grains. A low-fat diet with limited red meat may lower your breast cancer risk.^{28, 29, 30}
• Be active. Try to do at least 2½ hours a week of moderate exercise. One way to do this is to be active 30 minutes a day, at least 5 days a week.^{5, 31} Staying active may lower your breast cancer risk.³²
• Drink no more than one alcoholic drink a day.⁴ Using alcohol leads to extra estrogen in the body, which raises your breast cancer risk.¹⁰

"Anti-estrogen" medicine

If you are at high risk for breast cancer, talk to your doctor about taking medicine that helps prevent it. This is sometimes called hormone therapy for breast cancer. It blocks the effects of hormones on breast cancer cells.

• Tamoxifen is a medicine that blocks the effect of estrogen on breast cancer cells and normal breast cells. Among high-risk women, tamoxifen lowers their risk of breast cancer about the same as raloxifene does.³³ But this medicine may also increase other risks, such as for endometrial cancer, stroke, and blood clots in veins and in the lungs.
• Raloxifene is widely used to prevent and treat osteoporosis. It works like estrogen on bone, but it works like an "anti-estrogen" on breast tissue.³⁴ Among high-risk women, raloxifene lowers their breast cancer risk about the same as tamoxifen does. Compared to tamoxifen, raloxifene's endometrial cancer risk is lower.³³

The U.S. Food and Drug Administration (FDA) has approved raloxifene for use in reducing the risk of breast cancer in postmenopausal women who have osteoporosis. The FDA has also approved raloxifene for use in postmenopausal women at high risk for breast cancer.

If you are at high risk for breast cancer

If you are concerned that you may have an increased risk of developing breast cancer, talk with your doctor about whether you should take tamoxifen or raloxifene to prevent breast cancer. It is important to consider both their benefits and risks.

If you have a strong family history of early breast cancer or breast and ovarian cancer, talk to your doctor about BRCA testing. For more information, see:

Should I have a gene test for breast cancer?

What should I do if I'm at high risk for breast cancer?

Surgery to remove the breasts. Some women with a strong family history of breast cancer decide to have surgery to remove their breasts. This called a preventive or prophylactic mastectomy. It reduces the risk of developing breast cancer by approximately 90% in women who have a strong family history of breast cancer. A cancer risk assessment, genetic test, and psychological counseling are recommended for women who may be considering this treatment option.³⁵

Surgery to remove the ovaries. Genetic mutations (called BRCA1 or BRCA2 gene changes) raise the risk of both breast cancer and ovarian cancer. Hormones made by the ovaries increase the risk of breast cancer. Removal of the ovaries (prophylactic oophorectomy) reduces the risk of breast or ovarian cancer in women with a genetic mutation. Such a decision is best made after a cancer risk assessment, genetic test, and counseling.³⁶

Should I have my ovaries removed to prevent ovarian cancer?

Home Treatment

In general, healthy habits such as eating a balanced diet and getting enough sleep and exercise can help control your symptoms from breast cancer treatment.²⁰ Aim for at least 2½ hours a week of moderate exercise.³¹ Even when you are feeling bad, do everything you can to get regular exercise. It's fine to be active in blocks of 10 minutes or more throughout your day and week. Try walking with a friend to help you stick to a routine. Study after study has shown that getting plenty of exercise:

• Improves chances of survival from breast cancer.³⁷
• Helps battle anemia during radiation or chemotherapy.³⁸
• Improves quality of life after breast cancer treatment.³⁹

For more information, see the topics Fitness and Healthy Eating.

Home treatment for cancer treatment side effects

During treatment for any stage of breast cancer, you can use home treatment to help manage the side effects that may occur with cancer treatment. Home treatment may be all that you need to manage the following common problems. Be sure to follow any instructions and take any medicines your doctor has given you to treat these symptoms.

• Nausea or vomiting. If you have problems with nausea and vomiting while you are taking chemotherapy or receiving radiation therapy, let your doctor know. Medicines are available to prevent and treat nausea and vomiting that may be caused by treatment. It is important to let your doctor know if you have nausea or vomiting in spite of the use of these medicines. Home treatment for nausea or vomiting includes watching for and treating early signs of dehydration, such as a dry mouth, sticky saliva, and reduced urine output with dark yellow urine. For more information on how to deal with these side effects, see:

  Cancer: Controlling nausea and vomiting from chemotherapy.

• Diarrhea. Some chemotherapy medicines can cause diarrhea. Let your doctor know if you have diarrhea while you are on treatment. (Radiation therapy to the chest should not cause diarrhea.) Home treatment for diarrhea includes resting your stomach and being alert for signs of dehydration. Check with your doctor before you use any nonprescription medicines for your diarrhea.
• Constipation. Pain medicines, chemotherapy, and medicines used to treat nausea and vomiting related to chemotherapy can sometimes cause constipation. Let your doctor know if you have problems with constipation after surgery or while you are on chemotherapy. (Radiation therapy to the chest should not cause constipation.) Home treatment for constipation includes regular exercise along with getting enough fluids and eating a diet that is high in fruits, vegetables, and fiber. Check with your doctor before you use a laxative for your constipation.
• Fatigue. Breast cancer and treatment for it can cause fatigue. The stress of being diagnosed and treated can also make you feel tired. Some fatigue is expected after surgery and during both chemotherapy and radiation therapy. Fatigue is often worse at the end of treatment or just after treatment is completed. It is also common for fatigue to last more than a year after breast cancer treatment.⁴⁰ Home treatment for fatigue includes making sure you get extra rest while you are receiving chemotherapy or radiation therapy. Let your symptoms be your guide, and try to balance exercise with rest. You may be able to stay with your usual routine and just get some extra sleep. Let your doctor know if you are having trouble with fatigue.

Other issues that arise may include:

• Hair loss from chemotherapy. Hair loss can be emotionally distressing. Not all chemotherapy medicines cause hair loss, and some people have only mild thinning that is noticeable only to them. Talk to your doctor about whether hair loss is an expected side effect with the medicines you will receive. Other treatments for breast cancer, including hormone therapy and radiation therapy, do not cause hair loss.
• Lymphedema, which is swelling of the arm. Normally, lymph nodes filter fluid as it flows through them, trapping bacteria, viruses, and other foreign substances, which are then destroyed by white blood cells called lymphocytes. Without normal lymph drainage, fluid can build up in the affected arm, and lymphedema can develop. Because lymph nodes are removed from under the arm to help determine the stage of your breast cancer, you can develop lymphedema. Medicines such as tamoxifen, radiation therapy, and injury to the lymph nodes can also cause lymphedema. Not everyone will have a problem with lymphedema. You can reduce your risk of developing lymphedema by protecting your arm on the side where you had surgery and letting your doctor know right away if you have swelling or redness in that arm.

  Lymphedema: Managing lymphedema

• Sleep problems. If you have trouble sleeping, you may find that having a regular bedtime, getting some exercise during the day, avoiding naps, and using other tips to relieve sleep problems may help you sleep more easily. Tell your doctor if you have persistent difficulty sleeping.
• Pain. Not all forms of cancer or cancer treatment cause pain. If pain occurs, many treatments are available to relieve it. Be sure to follow all instructions and take the medicines your doctor has given you to treat pain. You may use home treatment for pain to improve your physical and mental well-being. Be sure to discuss with your doctor any home treatment you use for pain.

Coping with stress

Discovering that you have breast cancer and then having treatment for it can be very stressful.

• You may be able to reduce your stress by talking about your feelings to others. Stress and tension affect our emotions. By discussing your feelings with others, you may be able to understand and cope with them. Learning relaxation techniques may also help you reduce your stress.
• Expressing yourself through writing, crafts, dance, or art is a good tension reliever. Some dance, writing, or art groups that are specifically for individuals diagnosed with cancer may be available.
• Join a support group. Talking about a problem with your spouse, a good friend, or other people with similar problems is a valuable way to reduce tension and stress. Social support is very important both during and after treatment. Talk to your doctor or contact the American Cancer Society to find out about support groups in your area. If you have access to the Internet, you may also find an online support group.
• Your feelings about your body may change after a diagnosis of breast cancer and the need for treatment. Adapting to your body image changes may involve talking openly about your concerns with your partner and discussing your feelings with your doctor. Your doctor may also be able to refer you to organizations that can offer additional support and information.

For more information about how to find support groups and activities, see the Other Places to Get Help section of this topic.

Complementary therapies, such as acupuncture, herbs, biofeedback, meditation, yoga, and vitamins, are sometimes used along with medical treatment. Some people feel that they benefit from some of these therapies. Before you try a complementary therapy, talk with your doctor about the possible value and potential side effects. Let your doctor know if you are already using any such therapies.

Complementary therapies are not meant to take the place of standard medical treatment, but they may improve your quality of life and help you deal with the stress and side effects of cancer treatment.

Medications

Treatment before surgery for breast cancer (neoadjuvant treatment)

In some cases, chemotherapy or hormone therapy is used before surgery to shrink the breast cancer. This is called neoadjuvant therapy. It may allow you to save your breast if the cancer is large. Talk with your doctor about the risks and benefits of neoadjuvant therapy and whether it is an option for you.

Treatment after surgery for breast cancer (adjuvant treatment)

Depending on a variety of factors, such as tumor size, grade, and lymph node involvement, you may have several treatment options. Hormone therapy, chemotherapy, or a combination of the two therapies may be used after surgery to try to destroy any cancer cells that may be left in your body. This is called adjuvant therapy, and it is used to lower the chances that your breast cancer will come back. Talk with your doctor about the risks and benefits of each type of treatment. Your personal preferences and considerations are important when choosing a treatment that is right for you.

Should I use chemotherapy for early-stage breast cancer?

Medicines to treat breast cancer

Tamoxifen or an aromatase inhibitor is recommended for estrogen receptor-positive (ER+) breast cancer. These medicines stop estrogen from fueling ER+ breast cancer. (Only tamoxifen is used before menopause. Aromatase inhibitors seem to be more effective than tamoxifen after menopause.)^{23, 21, 22, 33}

Trastuzumab (Herceptin) is recommended after surgery and chemotherapy for HER-2/neu breast cancer. This medicine targets the HER-2 protein. It helps chemotherapy work better.

Chemotherapy. A combination of medicines is generally used to treat breast cancer. The most commonly used combinations are:

• AC, which combines the medicines Adriamycin and Cytoxan. Taxol or Taxotere may sometimes be added.
• CMF, which combines the medicines Cytoxan, methotrexate, and 5-FU.

Medicines to control nausea and vomiting

Treatment of breast cancer can cause nausea and vomiting. Your doctor will prescribe medicines for you to take with your treatments and when you get home to help relieve any nausea that you may have. Medicines to control and prevent nausea and vomiting may include:⁴¹

• Serotonin antagonists, such as ondansetron (Zofran), granisetron (Kytril), palonosetron (Aloxi), or dolasetron (Anzemet). These medicines work by blocking the effects of a chemical that affects vomiting (serotonin), which is made in the brain and in the stomach. They are often more effective when they are combined with aprepitant and/or corticosteroids, such as dexamethasone. Corticosteroids reduce swelling in the part of the brain that controls nausea.
• Aprepitant (Emend), which prevents and controls nausea and vomiting by blocking the effects of a chemical in the brain. It is always used in combination with a serotonin antagonist and/or dexamethasone.
• Phenothiazines, such as promethazine and prochlorperazine. These medicines stop nausea and vomiting by reducing the activity of the central nervous system.
• Metoclopramide (Reglan), which increases the movements or contractions of the stomach and intestines. This decreases the amount of time it takes for the stomach contents to move through the digestive tract.
• Dimenhydrinate (Dramamine), which is often used to treat motion sickness. It relieves nausea by blocking motion signals to the brain.
• Benzodiazepines, which are medicines to reduce anxiety, such as lorazepam (Ativan) or alprazolam (Xanax). This medicine can help with both anxiety and nausea when used with other anti-nausea medicine.
• Antipsychotic medicine, such as haloperidol or olanzapine.

What to Think About

The side effects of chemotherapy depend mainly on the medicines you receive. As with other types of treatment, side effects vary from person to person.

Hormone-blocking treatments, such as tamoxifen or an aromatase inhibitor, act on cells all over the body but generally cause fewer side effects than chemotherapy. If you are deciding what type of medicine to use, weigh the side effects and risks along with the benefits for your type of cancer.

When taking tamoxifen, you will need a pelvic exam every year. If you have any vaginal bleeding, other than normal menstrual bleeding, tell your doctor as soon as possible. This can be a sign of uterine precancer.

Neither chemotherapy nor hormone therapy is likely to cure breast cancer that has spread to another area of the body (metastasized), but either therapy can reduce symptoms and may prolong life.

Surgery

Most people with breast cancer have surgery to remove the cancer. In most cases, a few of the lymph nodes under the arm are also removed and examined under the microscope to see whether cancer cells are present. This is called sentinel lymph node biopsy.¹⁶ When nearly all lymph nodes under the arm are removed, it is called axillary lymph node dissection. You are less likely to have swelling (lymphedema) after a sentinel node biopsy than an axillary dissection.

Even if your doctor removes all the cancer that can be seen at the time of your surgery, you may be given treatment with radiation therapy, chemotherapy, or hormone therapy after surgery to try to destroy any cancer cells that may be left. This is called adjuvant therapy.

What type of surgery should I have to treat early-stage breast cancer?

Surgery that allows you to keep your breast

Procedures include:

• Breast-conserving surgery (lumpectomy), which is the removal of the lump in the breast along with some of the tissue around it. This is sometimes called excisional biopsy or wide excision. It is usually followed by radiation therapy to the remaining breast tissue.
• Partial or segmental mastectomy, which is the removal of the area of the breast that contains cancer as well as some of the breast tissue around the tumor and the lining over the chest muscles below the tumor. Some of the lymph nodes under the arm are also removed and examined under the microscope (axillary lymph node dissection or sentinel lymph node biopsy). In most cases, radiation therapy follows.

For stages I, II, and IIIA breast cancer, breast-conserving surgery (lumpectomy) with radiation therapy has the same survival rate as mastectomy and some of the same side effects.⁴²

Removal of the breast (mastectomy)

Mastectomy procedures include:

• Total or simple mastectomy, which is the removal of the whole breast.
• Modified radical mastectomy, which is the removal of the breast, some of the lymph nodes under the arm, and sometimes part of the chest wall muscles.
• Radical mastectomy (Halsted radical mastectomy), which is the removal of the breast, chest muscles, and all of the lymph nodes under the arm. For many years, this was the most common operation for breast cancer. Radical mastectomy is rarely used now because it does not improve survival or risk for recurrence when compared with other surgical treatments.

Breast reconstruction

You may wish to talk to your doctor about breast reconstruction before you make a decision about which type of surgery to have for breast cancer. If you choose to have a mastectomy, a different surgeon with special expertise in reconstructive surgery may perform this operation at the same time as the mastectomy or after the mastectomy.

Your choice will depend on the size of the cancer, the size and shape of your breasts, the size and shape of your body, how active you are, and other details, such as whether you have chemotherapy or radiation. If you choose to have a mastectomy, discuss reconstructive surgery and the use of a breast prosthesis with your doctor. For more information about reconstructive surgery, see the topic Cosmetic Surgery and Procedures.

Should I have breast reconstruction after mastectomy?

Other Treatment

Radiation therapy

Radiation therapy is the use of high-energy X-rays to destroy cancer cells and shrink tumors. It lowers the risk of your cancer coming back in the breast or chest wall. Radiation therapy is used after breast-conserving surgery and sometimes after mastectomy, depending on how advanced the breast cancer is at the time of surgery.

Most people have radiation treatments every day, 5 days each week, for about 6 weeks. Radiation therapy also may be combined with other treatments, such as chemotherapy or hormone therapy.

The most common way to give radiation therapy is called external beam radiation. This method of treatment exposes the skin on the chest and under the arm to a carefully focused beam of radiation. You will not be able to see the radiation, but your skin will look slightly sunburned in the treated area (called the radiation field). Small marks are tattooed onto the skin to help identify the radiation area.

Sometimes tiny radioactive pellets are placed in or near the tumor site. This is called brachytherapy, internal radiation, or interstitial radiation. Giving an extra boost of radiation near where the tumor was removed may help keep the breast cancer from returning to that area.

Brachytherapy is often used with external beam radiation.

Side effects

Radiation therapy can cause many side effects. Fatigue is common, especially toward the end of your treatment and for several weeks afterward. For some women, fatigue can last a long time after treatment.

Exercise helps battle anemia during radiation treatment. Getting plenty of exercise has been shown to improve blood counts.³⁸ Try to do moderate activity at least 2½ hours a week.³¹ Even when you are feeling bad, do everything you can to get regular exercise. It's fine to be active in blocks of 10 minutes or more throughout your day and week. Walk with a friend to help you stick to a routine while you get added support. Balancing rest with activity is important. Try to match your activities to your energy levels. Be patient. It can take time to fully recover.

The skin on your breast and under your arm may become red, dry, tender, and itchy. Toward the end of treatment, the skin may become moist and "weepy." These effects are temporary, and the area will gradually heal when treatment is completed. Expose the area to air as much as possible to help the skin heal. Some types of clothing may rub the skin and cause irritation, so you may want to wear loose-fitting cotton clothes. You may feel more comfortable if you do not wear a bra until your skin heals.

Possible long-term effects

• Radiation treatment can cause long-lasting fatigue. This has been linked to inflammation in the body.⁴⁰
• Radiation treatment to the left breast area may cause later heart problems. It has been linked to a higher risk of heart disease later in life, compared to right-breast radiation. The risk is especially high for smokers.^{43, 44}

Complementary therapy

Complementary therapies, such as acupuncture, herbs, biofeedback, meditation, yoga, and vitamins, are sometimes used along with medical treatment. Some people feel that they benefit from some of these therapies.

Before you try a complementary therapy, talk to your doctor about the possible value and potential side effects. Let your doctor know if you are already using any such therapies.

Complementary therapies are not meant to take the place of standard medical treatment, but they may improve your quality of life and help you deal with the stress and side effects of cancer treatment.

Clinical trials

Other treatments for breast cancer are being tested in clinical trials. Ongoing trials may include:

• "Partial breast" radiation procedures. Several methods are being tested that use radioactive implants (brachytherapy) and concentrated high-energy X-rays (limited field external radiation) for 1 to 5 days to replace the standard 4 to 6 weeks of traditional radiation therapy. The goal of these clinical trials is to keep the cancer from returning but reduce the side effects as much as possible.
• The use of a medicine in a different way or the use of a new medicine, such as a biologic response modifier. A biological response modifier uses materials produced by your body or made in a lab to boost, direct, or restore your body's natural defenses against breast cancer.

Check with your doctor to see whether clinical trials are available in your area and whether you might be eligible.

Other Places To Get Help

Organizations

Related Information

• Breast Cancer, Metastatic or Recurrent
• Breast Problems
• Cancer Pain
• Early Disease Detection
• Fibrocystic Breasts
• Lymphedema
• Support Groups and Social Support

References

Citations

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