If you have a symptom or screening test result that suggests cancer, your doctor must find out whether it is due to cancer or to some other cause. Your doctor may ask about your personal and family medical history. You may have a physical exam. Your doctor also may order a mammogram or other imaging procedure. These tests make pictures of tissues inside the breast. After the tests, your doctor may decide no other exams are needed. Your doctor may suggest that you have a follow-up exam later on. Or you may need to have a biopsy to look for cancer cells.
Clinical Breast Exam
Your health care provider feels each breast for lumps and looks for other problems. If you have a lump, your doctor will feel its size, shape, and texture. Your doctor will also check to see if it moves easily. Benign lumps often feel different from cancerous ones. Lumps that are soft, smooth, round, and movable are likely to be benign. A hard, oddly shaped lump that feels firmly attached within the breast is more likely to be cancer.
Diagnostic mammograms are x-ray pictures of the breast. They take clearer, more detailed images of areas that look abnormal on a screening mammogram. Doctors use them to learn more about unusual breast changes, such as a lump, pain, thickening, nipple discharge, or change in breast size or shape. Diagnostic mammograms may focus on a specific area of the breast. They may involve special techniques and more views than screening mammograms.
An ultrasound device sends out sound waves that people cannot hear. The waves bounce off tissues. A computer uses the echoes to create a picture. Your doctor can view these pictures on a monitor. The pictures may show whether a lump is solid or filled with fluid. A cyst is a fluid-filled sac. Cysts are not cancer. But a solid mass may be cancer. After the test, your doctor can store the pictures on video or print them out. This exam may be used along with a mammogram.
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) uses a powerful magnet linked to a computer. MRI makes detailed pictures of breast tissue. Your doctor can view these pictures on a monitor or print them on film. MRI may be used along with a mammogram.
Your doctor may refer you to a surgeon or breast disease specialist for a biopsy. Fluid or tissue is removed from your breast to help find out if there is cancer.
Some suspicious areas can be seen on a mammogram but cannot be felt during a clinical breast exam. Doctors can use imaging procedures to help see the area and remove tissue. Such procedures include ultrasound-guided, needle-localized, or stereotactic biopsy.
Doctors can remove tissue from the breast in different ways:
- Fine-needle aspiration: Your doctor uses a thin needle to remove fluid from a breast lump. If the fluid appears to contain cells, a pathologist at a ab checks them for cancer with a microscope. If the fluid is clear, it may not need to be checked by a lab.
- Core biopsy: Your doctor uses a thick needle to remove breast tissue. A pathologist checks for cancer cells. This procedure is also called a needle biopsy.
- Surgical biopsy: Your surgeon removes a sample of tissue. A pathologist checks the tissue for cancer cells.
- An incisional biopsy takes a sample of a lump or abnormal area.
- An excisional biopsy takes the entire lump or area.
If cancer cells are found, the pathologist can tell what kind of cancer it is. The most common type of breast cancer is ductal carcinoma. Abnormal cells are found in the lining of the ducts. Lobular carcinoma is another type. Abnormal cells are found in the lobules.
You may want to ask your doctor the following questions before having a biopsy:
- What kind of biopsy will I have? Why?
- How long will it take? Will I be awake? Will it hurt? Will I have anesthesia? What kind?
- Are there any risks? What are the chances of infection or bleeding after the biopsy?
- How soon will I know the results?
- If I do have cancer, who will talk with me about the next steps? When?
Many women with breast cancer want to take an active part in making decisions about their medical care. It is natural to want to learn all you can about your disease and treatment choices. Knowing more about breast cancer helps many women cope.
Shock and stress after the diagnosis can make it hard to think of everything you want to ask your doctor. It often helps to make a list of questions before an appointment. To help remember what the doctor says, you may take notes or ask whether you may use a tape recorder. You may also want to have a family member or friend with you when you talk to the doctor - to take part in the discussion, to take notes, or just to listen. You do not need to ask all your questions at once. You will have other chances to ask your doctor or nurse to explain things that are not clear and to ask for more details.
Your doctor may refer you to a specialist, or you may ask for a referral. Specialists who treat breast cancer include surgeons, medical oncologists, and radiation oncologists. You also may be referred to a plastic surgeon.
Getting a Second Opinion
Before starting treatment, you might want a second opinion about your diagnosis and treatment plan. Many insurance companies cover a second opinion if you or your doctor requests it. It may take some time and effort to gather medical records and arrange to see another doctor. You may have to gather your mammogram films, biopsy slides, pathology report, and proposed treatment plan. Usually it is not a problem to take several weeks to get a second opinion. In most cases, the delay in starting treatment will not make treatment less effective. To make sure, you should discuss this delay with your doctor. Some women with breast cancer need treatment right away.
There are a number of ways to find a doctor for a second opinion:
- Your doctor may refer you to one or more specialists. At cancer centers, several specialists often work together as a team.
- A local or state medical society, a nearby hospital, or a medical school can usually provide the names of specialists.
Women with breast cancer have many treatment options. These include surgery, radiation therapy, chemotherapy, hormone therapy, and biological therapy. These options are described below. Many women receive more than one type of treatment.
The choice of treatment depends mainly on the stage of the disease. Treatment options by stage are described below.
Your doctor can describe your treatment choices and the expected results. You may want to know how treatment may change your normal activities. You may want to know how you will look during and after treatment. You and your doctor can work together to develop a treatment plan that reflects your medical needs and personal values.
Cancer treatment is either local therapy or systemic therapy:
- Local therapy: Surgery and radiation therapy are local treatments. They remove or destroy cancer in the breast. When breast cancer has spread to other parts of the body, local therapy may be used to control the disease in those specific areas.
- Systemic therapy: Chemotherapy, hormone therapy, and biological therapy are systemic treatments. They enter the bloodstream and destroy or control cancer throughout the body. Some women with breast cancer have systemic therapy to shrink the tumor before surgery or radiation. Others have systemic therapy after surgery and/or radiation to prevent the cancer from coming back. Systemic treatments also are used for cancer that has spread.
Because cancer treatments often damage healthy cells and tissues, side effects are common. Side effects depend mainly on the type and extent of the treatment. Side effects may not be the same for each woman, and they may change from one treatment session to the next.
Before treatment starts, your health care team will explain possible side effects and suggest ways to help you manage them.
At any stage of disease, supportive care is available to control pain and other symptoms, to relieve the side effects of treatment, and to ease emotional concerns.
You may want to talk to your doctor about taking part in a clinical trial, a research study of new treatment methods.
You may want to ask your doctor these questions before your treatment begins:
- What did the hormone receptor test show? What did other lab tests show?
- Do any lymph nodes show signs of cancer?
- What is the stage of the disease? Has the cancer spread?
- What is the goal of treatment? What are my treatment choices? Which do you recommend for me? Why?
- What are the expected benefits of each kind of treatment?
- What are the risks and possible side effects of each treatment? How can side effects be managed?
- What can I do to prepare for treatment?
- Will I need to stay in the hospital? If so, for how long?
- What is the treatment likely to cost? Will my insurance cover the cost?
- How will treatment affect my normal activities?
- Would a clinical trial be appropriate for me?
Surgery is the most common treatment for breast cancer. There are several types of surgery. Your doctor can explain each type, discuss and compare the benefits and risks, and describe how each will change the way you look:
- Breast-sparing surgery: An operation to remove the cancer but not the breast is breast-sparing surgery. It is also called breast-conserving surgery, lumpectomy, segmental mastectomy, and partial mastectomy. Sometimes an excisional biopsy serves as a lumpectomy because the surgeon removes the whole lump.
The surgeon often removes the underarm lymph nodes as well. A separate incision is made. This procedure is called an axillary lymph node dissection. It shows whether cancer cells have entered the lymphatic system.
After breast-sparing surgery, most women receive radiation therapy to the breast. This treatment destroys cancer cells that may remain in the breast.
- Mastectomy: An operation to remove the breast (or as much of the breast tissue as possible) is a mastectomy. In most cases, the surgeon also removes lymph nodes under the arm. Some women have radiation therapy after surgery.
Studies have found equal survival rates for breast-sparing surgery (with radiation therapy) and mastectomy for Stage I and Stage II breast cancer.
Sentinel lymph node biopsy is a new method of checking for cancer cells in the lymph nodes. A surgeon removes fewer lymph nodes, which causes fewer side effects. (If the doctor finds cancer cells in the axillary lymph nodes, an axillary lymph node dissection usually is done.)
In breast-sparing surgery, the surgeon removes the tumor in the breast and some tissue around it. The surgeon may also remove lymph nodes under the arm. The surgeon sometimes removes some of the lining over the chest muscles below the tumor.
In total (simple) mastectomy, the surgeon removes the whole breast. Some lymph nodes under the arm may also be removed.
In modified radical mastectomy, the surgeon removes the whole breast, and most or all of the lymph nodes under the arm. Often, the lining over the chest muscles is removed. A small chest muscle also may be taken out to make it easier to remove the lymph nodes.
You may choose to have breast reconstruction. This is plastic surgery to rebuild the shape of the breast. It may be done at the same time as a mastectomy or later. If you are considering reconstruction, you may wish to talk with a plastic surgeon before having a mastectomy.
The time it takes to heal after surgery is different for each woman. Surgery causes pain and tenderness. Medicine can help control the pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more relief. Any kind of surgery also carries a risk of infection, bleeding, or other problems. You should tell your health care provider right away if you develop any problems.
You may feel off balance if you've had one or both breasts removed. You may feel more off balance if you have large breasts. This imbalance can cause discomfort in your neck and back. Also, the skin where your breast was removed may feel tight. Your arm and shoulder muscles may feel stiff and weak. These problems usually go away. The doctor, nurse, or physical therapist can suggest exercises to help you regain movement and strength in your arm and shoulder. Exercise can also reduce stiffness and pain. You may be able to begin gentle exercises within days of surgery.
Because nerves may be injured or cut during surgery, you may have numbness and tingling in your chest, underarm, shoulder, and upper arm. These feelings usually go away within a few weeks or months. But for some women, numbness does not go away.
Removing the lymph nodes under the arm slows the flow of lymph fluid. The fluid may build up in your arm and hand and cause swelling. This swelling is lymphedema. Lymphedema can develop right after surgery or months to years later.
You will need to protect your arm and hand on the treated side for the rest of your life:
- Avoid wearing tight clothing or jewelry on your affected arm
- Carry your purse or luggage with the other arm
- Use an electric razor to avoid cuts when shaving under your arm
- Have shots, blood tests, and blood pressure measurements on the other arm
- Wear gloves to protect your hands when gardening and when using strong detergents
- Have careful manicures and avoid cutting your cuticles
- Avoid burns or sunburns to your affected arm and hand
You should ask your doctor how to handle any cuts, insect bites, sunburn, or other injuries to your arm or hand. Also, you should contact the doctor if your arm or hand is injured, swells, or becomes red and warm.
If lymphedema occurs, the doctor may suggest raising your arm above your heart whenever you can. The doctor may show you hand and arm exercises. Some women with lymphedema wear an elastic sleeve to improve lymph circulation. Medication, manual lymph drainage (massage), or use of a machine that gently compresses the arm may also help. You may be referred to a physical therapist or another specialist.
You may want to ask your doctor these questions before having surgery:
- What kinds of surgery can I consider? Is breast-sparing surgery an option for me? Which operation do you recommend for me? Why?
- Will my lymph nodes be removed? How many? Why?
- How will I feel after the operation? Will I have to stay in the hospital?
- Will I need to learn how to take care of myself or my incision when I get home?
- Where will the scars be? What will they look like?
- If I decide to have plastic surgery to rebuild my breast, how and when can that be done? Can you suggest a plastic surgeon for me to contact?
- Will I have to do special exercises to help regain motion and strength in my arm and shoulder? Will a physical therapist or nurse show me how to do the exercises?
- Is there someone I can talk with who has had the same surgery I'll be having?
Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. Most women receive radiation therapy after breast-sparing surgery. Some women receive radiation therapy after a mastectomy. Treatment depends on the size of the tumor and other factors. The radiation destroys breast cancer cells that may remain in the area.
Some women have radiation therapy before surgery to destroy cancer cells and shrink the tumor. Doctors use this approach when the tumor is large or may be hard to remove. Some women also have chemotherapy or hormone therapy before surgery.
Doctors use two types of radiation therapy to treat breast cancer. Some women receive both types:
- External radiation: The radiation comes from a large machine outside the body. Most women go to a hospital or clinic for treatment. Treatments are usually 5 days a week for several weeks.
- Internal radiation (implant radiation): Thin plastic tubes (implants) that hold a radioactive substance are put directly in the breast. The implants stay in place for several days. A woman stays in the hospital while she has implants. Doctors remove the implants before she goes home.
Side effects depend mainly on the dose and type of radiation and the part of your body that is treated.
It is common for the skin in the treated area to become red, dry, tender, and itchy. Your breast may feel heavy and tight. These problems will go away over time. Toward the end of treatment, your skin may become moist and "weepy." Exposing this area to air as much as possible can help the skin heal.
Bras and some other types of clothing may rub your skin and cause soreness. You may want to wear loose-fitting cotton clothes during this time. Gentle skin care also is important. You should check with your doctor before using any deodorants, lotions, or creams on the treated area. These effects of radiation therapy on the skin will go away. The area gradually heals once treatment is over. However, there may be a lasting change in the color of your skin.
You are likely to become very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can.
Although the side effects of radiation therapy can be distressing, your doctor can usually relieve them.
You may want to ask your doctor these questions before having radiation therapy:
- How will radiation be given?
- When will treatment start? When will it end? How often will I have treatments?
- How will I feel during treatment? Will I be able to drive myself to and from treatment?
- How will we know the treatment is working?
- What can I do to take care of myself before, during, and after treatment?
- Will treatment affect my skin?
- How will my chest look afterward?
- Are there any long-term effects?
- What is the chance that the cancer will come back in my breast?
- How often will I need checkups?
Chemotherapy uses anticancer drugs to kill cancer cells. Chemotherapy for breast cancer is usually a combination of drugs. The drugs may be given as a pill or by injection into a vein (IV). Either way, the drugs enter the bloodstream and travel throughout the body.
Women with breast cancer can have chemotherapy in an outpatient part of the hospital, at the doctor's office, or at home. Some women need to stay in the hospital during treatment.
Side effects depend mainly on the specific drugs and the dose. The drugs affect cancer cells and other cells that divide rapidly:
- Blood cells: These cells fight infection, help your blood to clot, and carry oxygen to all parts of the body. When drugs affect your blood cells, you are more likely to get infections, bruise or bleed easily, and feel very weak and tired. Years after chemotherapy, some women have developed leukemia (cancer of the blood cells).
- Cells in hair roots: Chemotherapy can cause hair loss. Your hair will grow back, but it may be somewhat different in color and texture.
- Cells that line the digestive tract: Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores.
Your doctor can suggest ways to control many of these side effects.
Some drugs used for breast cancer can cause tingling or numbness in the hands or feet. This problem usually goes away after treatment is over. Other problems may not go away. In some women, the drugs used for breast cancer may weaken the heart.
Some anticancer drugs can damage the ovaries. The ovaries may stop making hormones. You may have symptoms of menopause. The symptoms include hot flashes and vaginal dryness. Your menstrual periods may no longer be regular or may stop. Some women become infertile (unable to become pregnant). For women over the age of 35, infertility is likely to be permanent.
On the other hand, you may remain fertile during chemotherapy and be able to become pregnant. The effects of chemotherapy on an unborn child are not known. You should talk to your doctor about birth control before treatment begins.
Some breast tumors need hormones to grow. Hormone therapy keeps cancer cells from getting or using the natural hormones they need. These hormones are estrogen and progesterone. Lab tests can show if a breast tumor has hormone receptors. If you have this kind of tumor, you may have hormone therapy.
This treatment uses drugs or surgery:
- Drugs: Your doctor may suggest a drug that can block the natural hormone. One drug is tamoxifen, which blocks estrogen. Another type of drug prevents the body from making the female hormone estradiol. Estradiol is a form of estrogen. This type of drug is an aromatase inhibitor. If you have not gone through menopause, your doctor may give you a drug that stops the ovaries from making estrogen.
- Surgery: If you have not gone through menopause, you may have surgery to remove your ovaries. The ovaries are the main source of the body's estrogen. A woman who has gone through menopause does not need surgery. (The ovaries produce less estrogen after menopause.)
The side effects of hormone therapy depend largely on the specific drug or type of treatment. Tamoxifen is the most common hormone treatment. In general, the side effects of tamoxifen are similar to some of the symptoms of menopause. The most common are hot flashes and vaginal discharge. Other side effects are irregular menstrual periods, headaches, fatigue, nausea, vomiting, vaginal dryness or itching, irritation of the skin around the vagina, and skin rash. Not all women who take tamoxifen have side effects.
It is possible to become pregnant when taking tamoxifen. Tamoxifen may harm the unborn baby. If you are still menstruating, you should discuss birth control methods with your doctor.
Serious side effects of tamoxifen are rare. However, it can cause blood clots in the veins. Blood clots form most often in the legs and in the lungs. Women have a slight increase in their risk of stroke.
Tamoxifen can cause cancer of the uterus. Your doctor should perform regular pelvic exams. You should tell your doctor about any unusual vaginal bleeding between exams.
When the ovaries are removed, menopause occurs at once. The side effects are often more severe than those caused by natural menopause. Your health care provider can suggest ways to cope with these side effects.
Biological therapy helps the immune system fight cancer. The immune system is the body's natural defense against disease.
Some women with breast cancer that has spread receive a biological therapy called Herceptin® (trastuzumab). It is a monoclonal antibody. It is made in the laboratory and binds to cancer cells.
Herceptin is given to women whose lab tests show that a breast tumor has too much of a specific protein known as HER2. By blocking HER2, it can slow or stop the growth of the cancer cells.
Herceptin is given by vein. It may be given alone or with chemotherapy.
The first time a woman receives Herceptin, the most common side effects are fever and chills. Some women also have pain, weakness, nausea, vomiting, diarrhea, headaches, difficulty breathing, or rashes. Side effects usually become milder after the first treatment.
Herceptin also may cause heart damage. This may lead to heart failure. Herceptin can also affect the lungs. It can cause breathing problems that require a doctor at once. Before you receive Herceptin, your doctor will check for your heart and lungs. During treatment, your doctor will watch for signs of lung problems.
You may want to ask your doctor these questions before having chemotherapy, hormone therapy, or biological therapy:
- What drugs will I be taking? What will they do?
- If I need hormone treatment, would you recommend drugs or surgery to remove my ovaries?
- When will treatment start? When will it end? How often will I have treatments?
- Where will I go for treatment? Will I be able to drive home afterward?
- What can I do to take care of myself during treatment?
- How will we know the treatment is working?
- Which side effects should I tell you about?
- Will there be long-term effects?
Treatment Choices by Stage
Your treatment options depend on the stage of your disease and these factors:
- The size of the tumor in relation to the size of your breast
- The results of lab tests (such as whether the breast cancer cells need hormones to grow)
- Whether you have gone through menopause
- Your general health
Below are brief descriptions of common treatments for each stage. Other treatments may be appropriate for some women. Clinical trials can be an option at all stages of breast cancer.
Stage 0 breast cancer refers to lobular carcinoma in situ (LCIS) or ductal carcinoma in situ (DCIS):
- LCIS: Most women with LCIS do not have treatment. Instead, the doctor may suggest regular checkups to watch for signs of breast cancer.
Some women take tamoxifen to reduce the risk of developing breast cancer. Others may take part in studies of promising new preventive treatments.
Having LCIS in one breast increases the risk of cancer for both breasts. A very small number of women with LCIS try to prevent cancer with surgery to remove both breasts. This is a bilateral prophylactic mastectomy. The surgeon usually does not remove the underarm lymph nodes.
- DCIS: Most women with DCIS have breast-sparing surgery followed by radiation therapy. Some women choose to have a total mastectomy. Underarm lymph nodes are not usually removed. Women with DCIS may receive tamoxifen to reduce the risk of developing invasive breast cancer.
Stages I, II, IIIA, and Operable IIIC
Women with Stage I, II, IIIA, and operable (can treat with surgery) IIIC breast cancer may have a combination of treatments. Some may have breast-sparing surgery followed by radiation therapy to the breast. This choice is common for women with Stage I or II breast cancer. Others decide to have a mastectomy.
With either approach, women (especially those with Stage II or IIIA breast cancer) often have lymph nodes under the arm removed. The doctor may suggest radiation therapy after mastectomy if cancer cells are found in 1 to 3 lymph nodes under the arm, or if the tumor in the breast is large. If cancer cells are found in more than 3 lymph nodes under the arm, the doctor usually will suggest radiation therapy after mastectomy.
The choice between breast-sparing surgery (followed by radiation therapy) and mastectomy depends on many factors:
- The size, location, and stage of the tumor
- The size of the woman's breast
- Certain features of the cancer
- How the woman feels about saving her breast
- How the woman feels about radiation therapy
- The woman's ability to travel to a radiation treatment center
Some women have chemotherapy before surgery. This is neoadjuvant therapy (treatment before the main treatment). Chemotherapy before surgery may shrink a large tumor so that breast-sparing surgery is possible. Women with large Stage II or IIIA breast tumors often choose this treatment.
After surgery, many women receive adjuvant therapy. Adjuvant therapy is treatment given after the main treatment to increase the chances of a cure. Radiation treatment can kill cancer cells in and near the breast. Women also may have systemic treatment such as chemotherapy, hormone therapy, or both. This treatment can destroy cancer cells that remain anywhere in the body. It can prevent the cancer from coming back in the breast or elsewhere.
Stages IIIB and Inoperable IIIC
Women with Stage IIIB (including inflammatory breast cancer) or inoperable Stage IIIC breast cancer usually have chemotherapy. (Inoperable cancer means it cannot be treated with surgery.)
If the chemotherapy shrinks the tumor, the doctor then may suggest further treatment:
- Mastectomy: The surgeon removes the breast. In most cases, the lymph nodes under the arm are removed. After surgery, a woman may receive radiation therapy to the chest and underarm area.
- Breast-sparing surgery: The surgeon removes the cancer but not the breast. In most cases, the lymph nodes under the arm are removed. After surgery, a woman may receive radiation therapy to the breast and underarm area.
- Radiation therapy instead of surgery: Some women have radiation therapy but no surgery. The doctor also may recommend more chemotherapy, hormone therapy, or both. This therapy may help prevent the disease from coming back in the breast or elsewhere.
In most cases, women with Stage IV breast cancer have hormone therapy, chemotherapy, or both. Some also may have biological therapy. Radiation may be used to control tumors in certain parts of the body. These treatments are not likely to cure the disease, but they may help a woman live longer.
Many women have supportive care along with anticancer treatments. Anticancer treatments are given to slow the progress of the disease. Supportive care helps manage pain, other symptoms, or side effects (such as nausea). It does not aim to extend a woman's life. Supportive care can help a woman feel better physically and emotionally. Some women with advanced cancer decide to have only supportive care.
Recurrent Breast Cancer
Recurrent cancer is cancer that has come back after it could not be detected. Treatment for the recurrent disease depends mainly on the location and extent of the cancer. Another main factor is the type of treatment the woman had before.
If breast cancer comes back only in the breast after breast-sparing surgery, the woman may have a mastectomy. Chances are good that the disease will not come back again.
If breast cancer recurs in other parts of the body, treatment may involve chemotherapy, hormone therapy, or biological therapy. Radiation therapy may help control cancer that recurs in the chest muscles or in certain other areas of the body.
Treatment can seldom cure cancer that recurs outside the breast. Supportive care is often an important part of the treatment plan. Many patients have supportive care to ease their symptoms and anticancer treatments to slow the progress of the disease. Some receive only supportive care to improve their quality of life.