Breast cancer occurs when abnormal cells form a mass of extra tissue (a tumor) in the breast.
- Breast cancer is a general term for several different types of cancer that occur in the breast.
- The disease can be discovered by examination of the breasts (by yourself or a physician), mammography, ultrasound testing and/or biopsy.
- Treatment depends on the stage and type of the cancer, as well as your age and health.
- The two main categories of breast cancer are lobular and ductal carcinomas. Each has subtypes, which differ in their potential to spread to other body tissues. Treatment of breast cancer involves local and systemic treatment. Different specialists should be involved to optimize the treatment regime.
What is breast cancer?Breast cancer is a general term for different types of cancer that develop from breast tissue cells. When abnormal cells divide in an uncontrolled manner they can form a mass of extra tissue, or tumour, which can be benign or malignant. Benign tumour cells do not spread to other parts of the body, can usually be removed and do not recur. Malignant (cancerous) tumour cells can invade nearby tissues and break away from the primary tumour to form secondary tumours (metastases) elsewhere in the body.
The breast and lymph nodesThe breast contains 15 to 20 sections, or lobes. Each lobe has many smaller lobules or glands. Ducts transport milk from the glands to the nipple. Stroma (fatty tissue and ligaments) surrounds the ducts and lobules. The breast is supplied with blood and lymph vessels. Lymph vessels carry tissue fluid, or lymph, which contains immune system cells. Lymph vessels lead to small glands called lymph nodes (collections of immune system cells). Lymph node clusters draining from the breast occur under the arm, above the collarbone, in the chest and elsewhere in the body.
Most cancers begin in ducts or lobules; occasionally, tumours form in non-glandular tissue. Breast tissue fluid drains into underarm lymph nodes, which filter lymph and may form a barrier against cancer cells. Cancer cells may spread to the lymph nodes or may spread around the body to other organs via the blood system. Usually, the lymph nodes are affected first; thereafter the organs most likely to be affected are the lungs, liver, bone and brain. Once the cancer has spread to the axillary (underarm) lymph nodes, it is more likely to have spread in the blood stream to other organs than a cancer that is just in the breast.
Types of breast cancerBreast cancer is also categorized as invasive (infiltrating) or non-invasive (in situ). Invasive cancer can grow directly into other parts of the body, or travel in blood or lymph. Non-invasive cancers may become invasive and usually do not spread, unless they have an invasive component.
Invasive cancers may exist with non-invasive cancers. The cancer can be localised or multifocal. Occasionally, more than one primary tumour may be present at the same time.
These are some of the more common types of breast cancer:Infiltrating/Invasive Ductal Carcinoma (IDC) comprises 65-85% of cases. It begins in milk duct cells and can break through duct walls to invade fatty tissue. It can metastasize (spread) via blood or lymph. On a mammogram it is usually revealed as an irregular mass, microcalcifications or both. It may appear as a lump, which usually feels harder than a benign lump.
Infiltrating/Invasive Lobular Carcinoma (ILC) accounts for 5-10% of cases. It originates in milk-producing lobes, and can spread to fatty tissue and elsewhere in the body. On a mammogram, it may appear similar to IDC, but physical examination does not usually reveal a hard mass – rather a vague thickening of tissue. It can occur in more than one place in the breast (multicentric/multifocal) or in both breasts simultaneously (bilateral).
Three slow-growing invasive subtypes are Medullary, Mucinous and Tubular Carcinomas, together representing about 12% of cases. They have a better prognosis than other more common invasive cancers.
Inflammatory Carcinoma is an IDC subtype. Typically the breast becomes red, swollen and warm, and the skin thickens and may develop small bumps. This is due to rapid cancerous growth which blocks lymph vessels. In 90% of cases cancer has spread to the lymph nodes at diagnosis. Prognosis is poor: this cancer is aggressive and difficult to treat. It accounts for 1-4% of cases.
Paget's disease starts in milk ducts and can spread to the nipple and areola, causing crusting and scaling. There is usually a history of nipple inflammation or discomfort. It may be associated with in-situ or infiltrating carcinoma. If no lump can be felt, and a biopsy shows no invasive cancer, prognosis is good. The treatment is similar to invasive cancers.
Soft Tissue Tumors: Tumours may originate in the supportive tissue of the breast. These tumours are uncommon and tend to have a good outcome.
As more women have regular mammograms, doctors are detecting more "non-invasive" or pre-cancerous conditions before they become full-blown cancers. They include the following:
Ductal Carcinoma In Situ (DCIS), the most common non-invasive type, occurs when cancer cells fill ducts but haven't yet spread through the walls into fatty tissue. Most women diagnosed at this stage can be cured. Without treatment, 25% of cases lead to invasive cancer within 10 years. Therefore, DCIS is treated as if it were cancer – with mastectomy or lumpectomy (removal of the tumor and a surrounding rim of normal tissue), followed by radiation to destroy any remaining malignant cells.
Lobular Carcinoma In Situ (LCIS) has no symptoms or characteristic mammography pattern. It usually occurs in multiple sites in the same breast. The risk of developing invasive cancer with LCIS is approximately one percent per year, with an equal chance of it occurring in either breast regardless of which breast had LCIS initially. LCIS is less common and less threatening than DCIS. It develops in milk-producing lobes and, when treated, does not penetrate lobule walls. LCIS does not usually become invasive itself, but may increase the risk of developing invasive cancer. For every 1 000 women with LCIS, 7.2 develop cancer within 30 years. Women with LCIS should have a mammogram and two or three physical exams each year.
What causes breast cancer and who is at risk?The cause is unknown and may include several genetic, environmental, nutritional and hormonal factors.
The following risk factors have been identified:- Female gender: 11% of women develop breast cancer. (European figures based on a life expectancy of 76 years)
- Older age: 77% of women diagnosed with breast cancer are over 50.
- Having one first-degree relative (mother, sister or daughter) with breast cancer doubles risk; having two increases risk five-fold.
- Approximately 5-10% of breast cancers are the result of inherited mutations (changes) of the genes BRCA1 and BRCA2, which make proteins that help prevent cancerous growth. This cancer-preventing function is less effective with a mutated gene, and 50-60% of women with BRCA1 or BRCA2 mutations develop breast cancer by age 70.
- Risk increases significantly if you have had cancer of the breast, ovaries, uterus or colon. Cancer in one breast means a three to four-fold increased risk of developing cancer in the other breast.
- When a biopsy indicates abnormal cells that are not yet cancerous (atypical hyperplasia), there is moderately increased risk of developing cancer in future. Atypical hyperplasia is a benign condition associated with abnormal growth of cells. A patient with this diagnosis is very likely to develop a cancer at some time in the future.
- Risk increases slightly if you have had a benign breast lump.
- Having had chest area radiation therapy in childhood or youth increases risk.
- Obesity (being overweight) is a possible risk, especially after menopause.
- Diet high in saturated animal fats may increase risk.
- Compared to non-drinkers, women who consume one alcoholic drink daily may have a small increase in risk; those who have two to five drinks daily have about 1.5 times the risk.
- Exposure to oestrogen probably increases risk. Oestrogen stimulates cell division: the more cells divide, the more likely it is that some may become cancerous.
- Women with early onset of menstruation, late menopause, a menstrual cycle shorter or longer than average, no pregnancies or first pregnancy after 30, have slightly higher risk.
- Using oral contraceptives may slightly increase risk. Women who stopped using oral contraceptives over 10 years ago do not appear to have increased risk.
- More than 10 years of hormone replacement therapy (HRT) increases the risk. Risk returns to that of the general population within five years of stopping HRT.
- Recent research suggests that smoking may increase the risk.
Who gets breast cancer?As more women have mammograms and with improved detection and treatment options, rates of new cases and deaths from breast cancer have leveled off. Yet breast cancer is still the most common cancer in women.
The disease is more common in older women, urban areas, higher socio-economic groups, unmarried women and Jewish women. Caucasians (especially of northern European descent) are slightly more at risk. Asian and Hispanic women have lower risk. Incidence in black women, specifically those of African descent, is increasing.
Signs and symptoms of breast cancerSymptoms are not obvious in the early stages. Later symptoms may include:
Breast lumps: these are usually painless, but some cause a prickly sensation
Change in nipple appearance: the shape or the skin may change
Unusual nipple discharge: especially stained with blood
Change in the skin of the breast
A lump or swelling under the arm
Occasional symptoms include:Breast swelling
Vague discomfort in the breast
Breast pain or tenderness
Change in breast contour, texture or temperature
How is breast cancer diagnosed?This is based on the ‘triple assessment’. The physician will take a history and examine the patient. The radiologist will do a mammogram and/or an ultrasound. The cells of the lump may be sampled using a fine needle or by taking a core of tissue.
If all of the above suggest the lump is not malignant, the lump may be watched and followed up. If one of the tests casts any doubt, the lump should be removed.
If breast cancer is found relatively early, when tumors are small and confined to the breast, over 97% of women live for at least five years.
Clinical Assessment: There are two parts to this: the patient’s history and the examination. The general medical history from the patient includes the history of the illness, family history and past medical history of the patient. In a clinical examination, the examiner gently palpates (feels) your breasts, noting shape, texture, changes in skin and nipples and location of any lumps, as well as whether these are attached to skin or deeper tissues. Lymph nodes under the arm and above the collarbone are palpated for swelling.
Mammography: Low-intensity X-ray of the breast. This may be done for screening (If no abnormalities were found in an examination) or for diagnosis. A mammogram takes about 20 minutes and can detect many changes or abnormalities, before they grow large enough to be felt. Diagnostic mammography may indicate whether a breast lump is malignant or not.
If the mammogram was done for screening and shows an area of abnormal tissue that is probably benign, you return in four to six months for a re-check. If it shows no serious abnormality, regular screening programs should be adhered to. These include mammography screening and clinical screening. When the mammogram shows abnormalities, the radiologist may recommend another type of exam, such as a biopsy.
If the mammogram was done as a diagnostic test, the results must be seen in the light of the clinical findings and the biopsy.
What happens during a mammogram? You stand or sit in front of a special x-ray machine while the radiological technologist lifts each breast and positions it on a platform that holds x-ray film. A plastic plate presses the breast against the platform. Pressure for a few seconds means the x-ray dose can be lowered and ensures the x-ray shows as much breast tissue as possible. This pressure is harmless and usually not painful, but it can be uncomfortable. Avoid having mammograms when your breasts are tender, such as before your period.
Discuss results with your doctor. Calcifications are mineral deposits, which may appear as white spots on the film. They may be caused by benign conditions or, less often, by cancer. If the mammogram shows masses, these are usually biopsied if they are not cysts (benign collections of fluid).
Ultrasound or removal of fluid with a needle (aspiration) may confirm whether a mass is a cyst. Some masses are monitored with periodic mammograms; others require biopsy.
Mammograms can suggest but not prove the presence of cancer. Mammography detects 85-90% of breast cancers. Approximately 10-15% are not visible on mammography, but are felt on physical examination.
Breast ultrasound: sound waves are bounced off tissues and the echoes converted into a picture (sonogram). Ultrasound helps distinguish between cysts and solid tumors. It is particularly useful in younger patients whose breasts are too dense for mammography.
MRI: this is a technique that is being used to image the breast more and more but is still too expensive and specialized to be used routinely.
Nipple discharge examination: to check for cancer cells. Clear or milky secretions are less likely to result from cancer. A red-brown colour may indicate cancer, although benign conditions are more likely. Even when no cancer cells are found, cancer cannot be ruled out. If a suspicious mass is also present, a biopsy is necessary.
Biopsy (sampling of the tissue): This may be done as part of the assessment of a lump even though the clinical examination and the radiological examination suggest that the lump is not cancerous. Alternatively, an abnormality on a mammogram may be sampled using special radiological equipment. 80% of biopsies are non-cancerous.
Fine-needle aspiration biopsy: A needle is guided into the abnormal area while the doctor palpates the lump. Once the needle is in place, fluid is drawn out. Clear greenish fluid usually indicates a benign cyst. Bloody or cloudy fluid can mean a benign cyst or, rarely, cancer. With a solid lump, tissue cells are aspirated. In most cases, examination under a microscope will determine whether abnormalities are benign or cancerous.
Core needle biopsy: A small cylinder of tissue is removed from an abnormality.
If after the ‘triple assessment’ the lump is suspected to be cancerous or the diagnosis is still not known, then the lump should be removed.
Surgical biopsy: All or part of a lump is surgically removed for examination. Excisional biopsy removes the abnormality along with a surrounding margin of apparently normal tissue, and is usually considered the first of a two-step procedure. (A diagnosis of cancer by needle biopsy can also be considered the first step.) The second step is complete local treatment of the cancer through radiation therapy or additional surgery. With the two-step procedure for biopsy, a cancer diagnosis is known shortly after biopsy, but the extent of cancer is not known until after local treatment surgery.
If the abnormality is not a lump but a change on a mammogram that cannot be palpated, then the tissue has to be removed using a technique called a ‘hookwire biopsy’. The patient has another mammogram and the area of concern on the mammogram is located. The radiologist then places a wire into the area using the x-ray machine to guide it into position. The surgeon then cuts out the wire along with the surrounding tissue and sends it to be x-rayed again, to check the abnormal tissue has been removed.
Can breast cancer be prevented?At the moment breast cancer cannot be prevented, but it can be diagnosed much earlier than before. Early diagnosis is possible with routine mammography and early biopsy of suspicious lesions. The earlier cancer is found, the better the chances of a cure.
Women should have a baseline mammogram between the ages of 35 and 40. Between 40 and 50 years of age, mammograms are recommended every other year. After age 50, annual mammograms are recommended.
Between 20 and 39, women should have a clinical breast examination every three years, and annually from 39 on.
The following may help prevent breast cancer:A low-fat diet (less than 20% fat), with plenty of fruits and vegetables, and ideal weight maintenance.
When cancer is found and treated early, there are more treatment choices and a better chance of recovery. Talk to your doctor about symptoms to watch for, and an appropriate check-up schedule.
Between clinical check-ups, do a monthly breast self-exam (BSE). Every woman's breasts are different, and they change with age, the menstrual cycle, pregnancy, menopause, or taking oral contraceptives or other hormones. It may be normal for your breasts to feel lumpy, swollen or tender at times, such as immediately before a period or during pregnancy. By doing a monthly BSE, after age 20, you learn what is normal for your breasts, and are more likely to detect changes.
Breast-feeding may slightly decrease risk, especially if continued for 18-24 months. Strenuous exercise in youth might provide life-long protection. Even moderate physical activity as an adult can lower risk.
How is breast cancer treated?The treatment of breast cancer depends on the clinical stage of the cancer, the pathological type, as well as the patient’s age and wishes.
Treatment for invasive cancersInvasive cancers are staged according to the size of the primary breast cancer, the spread to the axillary nodes and evidence of spread elsewhere in the body.
Stage 1: the tumour in the breast is small and there is no evidence of spread anywhere
Stage 2: the primary tumour is <> 5cm or there is evidence of obvious lymphatic spread
Stage 4: there is evidence of spread to other organs such as lung, liver or bone
The treatment may be thought of as being aimed at the primary tumour, the lymph nodes or the whole body.
Treatment plans are divided into local and systemic therapy. Local therapy, such as surgery and radiation, aims to remove or kill cancer cells in the breast and adjacent lymph nodes. Systemic therapy may be in the form of chemotherapy or hormonal therapy. This may mean a tablet once a day or intravenous drugs.
In general:Stage 1 disease is treated locally, usually with surgery. There is a growing tendency to give patients hormonal therapy even when the disease is in such early stages.
Stage 2 disease is usually treated by surgery first and then systemic treatment afterwards. Systemic treatment given after local treatment when there is no sign of disease is known as adjuvant therapy.
Stage 3 disease is increasingly treated with systemic treatment first to ‘downstage’ the disease and with surgery afterwards. Systemic treatment given before local treatment is known as neoadjuvant therapy.
Stage 4 disease is usually treated systemically, although radiotherapy may be used.
Radiation therapy uses high-energy rays to reduce the size of the tumour or destroy cancer remaining in the breast area after surgery. It may be used to control the local tumour in stage 4 disease or may be used to treat local recurrence at a later date. It is generally painless and given as an outpatient. Side effects include fatigue, swelling and sunburn-like skin changes in the treated area. These changes usually disappear in six to 12 months. Radiation therapy is nearly always given after a lumpectomy.
Cancer can be cured by local therapy if it has not spread further. Unfortunately, cancer can spread even though the primary cancer is small and there is no evidence of spread to lymph nodes.
Breast cancer does not always follow predictable growth patterns, and a prognosis cannot be predicted with absolute certainty. Therefore, systemic therapy is incorporated to treat the potential and actual risk of cancer spreading.
Chemotherapy and hormonal therapy are systemic therapies, given via the bloodstream to kill cancer cells that have spread beyond the breast. Chemotherapy comprises drugs received intravenously or by mouth. Hormone therapy involves drugs that change the way hormones work, or the removal of hormone-producing organs such as the ovaries. More patients are being put on systemic treatment after apparently curative surgery as there is increasing evidence that patients are less likely to develop problems, such as recurrence, second primary in the remaining breast tissue or metastatic disease, if they take systemic treatment. The traditional roles of hormonal treatment and chemotherapy are constantly being challenged and are changing, although hormonal therapy in a tablet form is still the most common form of adjuvant therapy.
The surgical options must be considered from various angles: the treatment of the breast, the treatment of the lymph nodes and the question of reconstruction.
Mastectomy means removal of all the breast tissue. If this is done by a breast surgeon, 3-5% of the breast tissue will still be left between the muscle bundles or in the skin.
Originally, radical mastectomy was done as a standard procedure. It entails removal of the breast, underarm lymph nodes and chest muscles under the breast. Because of disfigurement and side effects, and because modified radical mastectomy has proved equally effective, radical mastectomy is now rarely done.
Modified radical mastectomy entails removal of the breast tissue, the fascia on top of the muscle and the lymph nodes. It is less disfiguring and may be done to achieve a flat chest wall or may be done through the nipple to allow immediate reconstruction.
Simple or total mastectomy removes the breast, but not underarm lymph nodes nor muscle tissue beneath the breast.
In certain circumstances, if the tumour is < 5cm, breast conservation therapy (BCT) may be a satisfactory option. This maintains the major part of the breast and often shape is not altered significantly. Both BCT and modified radical mastectomy are equally effective in the correct patients. BCT has to be followed by radiotherapy and so is contraindicated in patients who cannot have radiotherapy. Neither guarantees a cure as approximately 25-30% of all women with breast cancer ultimately die from their disease. (The chances or dying from the disease are related to the stage of the disease at the time it was first diagnosed.)
The axillary nodes can be dissected out through a separate incision at the time of BCT. If nodes are felt on clinical examination, they will nearly always be removed at the time of surgery. This may be as part of the mastectomy (modified radical mastectomy) or may be through a separate incision.
If there are no nodes palpable and there is no evidence of cancer spread to the axilla, a Sentinel Lymph Node Biopsy may be performed. A radioactive substance is injected into the cancerous region, and is carried by lymph vessels to a "sentinel node", which is the first lymph node receiving lymph from the tumour. If the sentinel node contains cancer, more nodes are removed.
If the sentinel node is cancer-free, additional lymph node surgery may be avoided. This is being done more frequently but the final usage of this technique has to be established.
After surgery, lymph node status is known. To determine whether cancer has spread to axillary lymph nodes, some are removed and examined (axillary dissection).
If cancer has spread to lymph nodes, risk of recurrence is much higher and chemotherapy and/or hormonal therapy are usually needed.
Risk of metastasis roughly increases with the size of the original tumor, spread to lymph nodes, number of nodes involved and microscopic characteristics of the cancer. No tests can show precisely whether there is microscopic metastasis. Even when the tumor is small and there is no evidence of spread to lymph nodes, there may be reasons to use adjuvant systemic therapy, as about 10-15% of women in this group will develop metastatic cancer.
Chemotherapy in adjuvant treatment usually involves a combination of drugs, in six cycles encompassing about six months of therapy.
Side effects depend on the drug type, amount and length of treatment. Temporary side effects may include nausea and vomiting, loss of appetite, hair loss, mouth sores and menstrual cycle changes. Chemotherapy can damage blood-producing bone marrow cells, resulting in low blood cell counts. A shortage of white blood cells, red blood cells and platelets increases the risk of infection, fatigue and bleeding or bruising respectively. Premature menopause and infertility are potential permanent complications. The chemotherapy drug adriamycin (doxorubicin) may cause permanent heart damage, but doctors carefully control dosage and use it for patients that are unlikely to suffer permanent damage. In rare cases, certain chemotherapy drugs may cause acute myeloid leukemia or AML, a white blood cell cancer that can occur years after treatment.
Hormone TherapyOestrogen promotes growth of some breast cancers. If hormone receptors are present, anti-oestrogenic agents such as tamoxifen can be used. Tamoxifen is taken daily in pill form for two to five years, as adjuvant therapy or to treat metastatic cancer. In post-menopausal women tamoxifen can decrease risk of recurrence similar to the decrease with chemotherapy, without many of the side effects associated with chemotherapy. It can also be given following completion of chemotherapy as, in certain women, it can decrease risk of recurrence more than with chemotherapy alone.
This drug helps women with breast cancer in its early stages, regardless of age. Tamoxifen may increase risk of early stage cancer of the uterine lining. Other effects may include weight gain, hot flushes, mood swings, blood clots and cataracts.
Megestrol acetate is used for treatment of advanced cancers that do not respond to tamoxifen.
Adding progestins or androgens (male hormones) may also be considered in advanced cancer. Side effects depend on drugs used: fluid retention is most common with progestins, while androgens can cause masculine characteristics such as more body hair, deeper voice and so on.
Inflammatory breast cancer has sometimes metastasized by the time of diagnosis. Chemotherapy is started immediately, followed by radiation therapy and surgery.
Autologous Peripheral Blood Stem Cell or Bone Marrow TransplantationThis procedure is rarely used. It occurs before chemotherapy takes place. Some stem (blood-producing) cells are removed from peripheral (circulating) blood or bone marrow and returned after treatment. Stem cells re-establish themselves and restore blood cell production. Growth factors (hormone-like drugs that stimulate bone marrow stem cells) may be added to boost blood cell production.
Bone marrow or peripheral blood stem cell transplantation may be used as adjuvant therapy in some women with a high risk of recurrence or for treatment of advanced disease. It is not mainstay treatment.
Treatment for Non-invasive CancersTreatment of Ductal Carcinoma In Situ (DCIS) is based on the risk of it evolving into invasive cancer and the fact that it is a curable disease. Treatment options include lumpectomy, lumpectomy with radiation therapy, and simple mastectomy. If the abnormal area is small, then removing this alone may suffice. Further therapy is usually indicated for a larger abnormal area, because risk of recurrence is reasonably high. In 50% of cases, recurring cancer is invasive. With simple mastectomy, the cure rate is 98-99%.
Lobular Carcinoma In Situ (LCIS) is not pre-invasive, but represents high-risk potential for development of invasive cancer. No treatment is required, but affected women should be monitored with mammograms and physical exams. Lumpectomy with or without radiation does not significantly decrease the risk of developing invasive breast cancer with LCIS. A single mastectomy is not a solution either, since invasive cancer can occur in either breast.
Prophylactic mastectomy is chosen occasionally by women with LCIS who are at very high risk of developing invasive cancer: both breasts are removed before cancer is diagnosed. This should be considered only if you are young at diagnosis, as the cumulative one percent per year risk of developing invasive cancer can be substantial after many years, and/or there are other significant risks, such as mutated BRCA genes, previous breast cancer and a strong family history of breast cancer.
Side effects and post-surgical recoveryClearly these depend on the surgery. There are complications from the anaesthetic and those from the operation itself.
After a lumpectomy, it is usual to feel a mass there which takes months to settle. Eventually, the tissue under the scar will feel similar to the remaining breast tissue but this takes many months. After a mastectomy there may be some areas of skin that do not survive. This isn’t usually a major problem but may be more problematic if immediate reconstruction is done at the time using the patient’s breast skin.
If the operation has included removal of the axillary lymph nodes (Modified radical mastectomy, axillary dissection or radical mastectomy) then other side effects may occur. A major side effect is lymphoedema, which occurs in about10-20% of women. Lymphoedema is swelling of the arm due to fluid accumulation. Axillary dissection or radiation to the axillary lymph nodes may disrupt lymph drainage from that arm, causing fluid build-up. It is more likely to occur if there has been surgery and radiotherapy. Lymphoedema can occur immediately after surgery, or months or even years later.
The potential for developing lymphoedema remains for life. Injury or infection involving the affected arm can aggravate existing lymphoedema or trigger its development, so the arm and hand should be protected. Avoid having blood drawn from the affected arm, and report swelling, tightness, pain or injury to the arm or hand to your doctor promptly.
There may be temporary or permanent limitations to arm and shoulder movement after surgery. Numbness or pinching/pulling sensations of upper inner arm skin is another common side effect, because the nerve controlling this travels through the lymph node area.
After surgery, you may need drains from the breast or underarm to remove fluid that collects during healing. Fluid must be emptied and measured while drains remain in place, for about two weeks. Some doctors put the arm in a sling, but most encourage moving the arm to avoid stiffness. Most women who have lumpectomy or mastectomy have little pain in the breast area. Written instructions on post-operative care are usually provided for the patient and the caregiver.
Most patients see their doctor within seven to 14 days after surgery. Your doctor should discuss the results of your pathology report and further treatment.
Long term follow up (the outcome)The management of a patient who has been treated for breast cancer includes life-long surveillance. This is to detect any disease progression early and to check if there is a chance of the patient developing a second cancer. After finishing the first course of treatment, it is important to continue with scheduled follow-up appointments. During these appointments, your doctors will ask about any symptoms, do physical examinations and order laboratory or imaging tests as needed to look for recurrences or side effects.
At first, follow-up physical exams are done every three to four months. The longer you are free of cancer, the less often exams are needed. After five years, they are done once a year. Annual mammograms of the remaining breast and the breast treated by lumpectomy are needed. Women taking tamoxifen should have annual pelvic examinations.
A chest x-ray, CT scan, bone scan and a biopsy may be done if initial exams and tests suggest a recurrence. Depending on the location of a recurrent cancer, treatment may involve surgery, radiation therapy, hormonal therapy or chemotherapy.
Reconstructive Surgery and Breast Implant SurgeryThe aim of re-constructive surgery for the majority of women who have had breast cancer is to have symmetrical breasts. This may be achieved in two ways: the unoperated breast may be reduced or the operated breast may be reconstructed.
About a third of mastectomy patients choose to have the breast rebuilt using prosthetic implants and/or tissue from other parts of the body (autologous tissue reconstruction). Breast reconstruction may be done at the same time as the mastectomy (immediate reconstruction) or after post-operative healing (delayed reconstruction). Immediate reconstruction may lessen the emotional impact of mastectomy, but the operation is longer and increases the chance of problems as the wound heals.
If chemotherapy is part of the treatment plan, surgeons are more likely to recommend delayed reconstruction. They also take size and location of the cancer into account, as well as health factors such as age, obesity and whether you smoke or have diabetes.
Lumpectomy patients may benefit from reconstruction if a large amount of tissue has been excised. However, a lumpectomy is usually followed by radiation therapy, and irradiated tissue tends to heal poorly. Changes may continue in the shape of the breast for months after treatment. For the majority, the aim of BCT is to avoid reconstruction.
There are several methods of autologous reconstruction (reconstruction using the patient’s own tissue):TRAM (transverse rectus abdominous muscle) flap: A section of skin, underlying fat and a portion of abdominal muscle is excised from the abdominal wall. The tissue (skin and fat) requires its own blood supply. This is taken from the underlying muscle: the rectus abdominus so leaving a flap of tissue with the natural blood supply. The flap is tunnelled under the abdominal wall to the chest and to cover the mastectomy wound. The edges of the breast incision are sutured to the flap. The TRAM flap creates a natural texture and can be shaped to match the other breast. Some women experience abdominal weakness, and there is increased risk of developing abdominal hernia (bulging of internal tissues through an area of abdominal wall weakness). The patient’s natural breast skin may be used or the skin may be transplanted from the tummy. The advantage is that a ‘tummy tuck” is done at the same time. A disadvantage is that it is a long procedure and more painful than a mastectomy.
Free flap: This is rarely performed. An “island" of fat and skin is cut free from the abdomen and stitched in place over the mastectomy wound. Microsurgery attaches the blood vessels supplying the flap to those in the chest wall. Since it is not necessary to remove as much abdominal muscle, some side effects of the TRAM procedure are avoided.
Latissimus dorsi flap: A section of muscle and skin is removed from the back, attached to a pedicle, with the blood supply of the flap. The flap is tunnelled under the skin, pulled out through an opening in the chest, sutured over the mastectomy site and an implant placed under the muscle. This procedure leaves a scar on the back, and there is potential for shoulder problems because some muscle governing shoulder movement is removed.
Autologous breast reconstruction can take several hours. Immediate complications are those associated with any operation: infection, blood clots and accumulation of blood and/or fluid in the breast or donor site. Healing complications are more likely, though uncommon. If the blood supply is inadequate, skin over the reconstructed breast may die, requiring another operation. Sometimes fatty tissue degenerates and causes thickening that feels painful and similar to a lump. These methods are much more complicated than inserting an implant, but they usually produce a better result than an implant alone, particularly in women with large breasts, or after radiation.
Surgery to insert an implant is relatively simple. When done at the time of a mastectomy, the reconstruction adds 30-60 minutes. Recovery time is longer, but aftercare is the same as for mastectomy alone. Delayed reconstruction requires about 90 minutes. An implant is usually inserted through the mastectomy incision and beneath the pectoralis muscle in the chest. The surgeon may insert the implant through a new incision on the side of the breast nearest the armpit.
If there is not enough skin left after a mastectomy to place an implant, the surgeon inserts a tissue expander to stretch the muscle and skin over the chest wall. The tissue expander is a silicone envelope that is flat on initial insertion. Every week or two for a few months, saline is injected through a valve until the expander is inflated to a size slightly larger than the implant. This painlessly stretches the skin until the surgeon can replace the expander with a permanent implant, in a 30-minute operation that can be done as an outpatient. Some implants combine the expander and the permanent implant. After the skin expansion is complete, the filling valve is sealed and the expander remains as a permanent implant.
Implants come in various shapes and sizes. In matching the opposite breast, women with small to medium rounded breasts have the best results.
There was some controversy over the safety of silicone gel implants. Many women prefer them to saline implants as silicone gel feels more like breast tissue. If a leak occurs, saline is absorbed harmlessly into the body, but there is concern that silicone may trigger conditions in which the immune system attacks normal tissues, although this has been shown not to be a major problem.
As with any surgery, there is a risk of post-operative complications such as infection, seroma (accumulation of fluid) and bleeding. Reconstruction may also cause loss of sensation in the breast, movement of the implant, breast asymmetry and extrusion, in which the implant begins to push out through the healing incision. A common complication is capsular contraction, where the scar tissue that forms around the implant becomes abnormally hard and contracts over the implant, causing the reconstruction to be misshapen.
Nipple reconstruction can be done in conjunction with re-constructive breast procedures, usually after the reconstruction has healed. Usually tissue from the upper inner thigh is used. The areola can be tattooed with flesh-colored pigment.
Women who reject reconstruction may not want the risks and discomfort of additional surgery, and some women feel comfortable wearing prostheses. In general, older women are less likely to have reconstruction, since it involves more operative time and more complications.
When to see your doctorIf you find a lump in your breast at any age or at any stage of your menstrual cycle you should see your doctor as soon as possible.
Labels: About Breast Cancer