Through continuing research into new treatment methods, women now have more treatment options and hope for survival than ever before. The treatment options for each woman depend on the size and location of the tumor in her breast, the results of lab tests (including hormone receptor tests), and the stage (or extent) of the disease. To develop a treatment plan to fit each patient's needs, the doctor also considers a woman's age and menopausal status, her general health, and the size of her breasts.

Many women want to learn all they can about their disease and their treatment choices so that they can take an active part in decisions about their medical care. They are likely to have many questions and concerns about their treatment options.

The doctor is the best person to answer questions about treatment for a particular patient: what her treatment choices are, how successful her treatment is expected to be, and how much it is likely to cost. Most patients also want to know how they will look after treatment and whether they will have to change their normal activities. Also, the patient may want to talk with her doctor about taking part in a clinical trial, a research study involving people, of new treatment methods.

The National Cancer Institute also has a Web site at http://cancertrials.nci.nih.gov/ that offers detailed information about clinical trials for patients, health professionals, and the public.

Many patients find it helpful to make a list of questions before seeing the doctor. To make it easier to remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some patients also find that it helps to have a family member or friend with them when they see the doctor--to take part in the discussion, to take notes, or just to listen.

Here are some questions a woman may want to ask the doctor before treatment begins:

• What are my treatment choices?
• What are the expected benefits of each kind of treatment?
• What are the risks and possible side effects of each treatment?
• Are new treatments under study? Would a clinical trial be appropriate for me?

There is a lot to learn about breast cancer and its treatment. Patients should not feel that they need to ask all their questions or understand all the answers at once. They will have many other chances to ask the doctor to explain things that are not clear and to ask for more information.

Planning Treatment

Before starting treatment, the patient might want a second opinion about the diagnosis and the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if the patient requests it. It may take a week or two to arrange to see another doctor. Studies show that a brief delay (up to several weeks) between biopsy and treatment does not make breast cancer treatment less effective.

There are a number of ways to find a doctor for a second opinion:

• The patient's doctor may refer her to one or more specialists. Specialists who treat breast cancer include surgeons, medical oncologist, plastic surgeon", and radiation oncologists. Sometimes these doctors work together at cancer centers or special centers for breast diseases.
• Patients can get the names of specialists from their local medical society, a nearby hospital, or a medical school.
• The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and their background. This resource, produced by the American Board of Medical Specialties, is available in most public libraries.

Methods of Treatment

Methods of treatment for breast cancer are local therapy or systemic. Local treatments are used to remove, destroy, or control the cancer cells in a specific area. Surgery and radiation therapy are local treatments. Systemic treatments are used to destroy or control cancer cells throughout the body. Chemotherapy and hormonal therapy are systemic treatments. A patient may have just one form of treatment or a combination. Different forms of treatment may be given at the same time or one after another.

Surgery is the most common treatment for breast cancer. Several types of surgery may be used. The doctor can explain each of them in detail, discuss and compare the benefits and risks of each type, and describe how each will affect the patient's appearance. An operation to remove the breast (or as much of the breast as possible) is a mastectomy. Breast reconstruction is often an option at the same time as the mastectomy, or later on. An operation to remove the cancer but not the breast is called breast-sparing surgery or breast-conserving surgery. Lumpectomy and segmental mastectomy (also called partial mastectomy) are types of breast-sparing surgery. They usually are followed by radiation therapy to destroy any cancer cells that may remain in the area. In most cases, the surgeon also removes lymph nodes under the arm to help determine whether cancer cells have entered the lymphatic system.

In lumpectomy, the surgeon removes the breast cancer and some normal tissue around it. Often, some of the lymph nodes under the arm are removed.

In segmental mastectomy, the surgeon removes the cancer and a larger area of normal breast tissue around it. Occasionally, some of the lining over the chest muscles below the tumor is removed as well. Some of the lymph nodes under the arm may also be removed.

In total mastectomy, the surgeon removes the whole breast. Some of the lymph nodes under the arm may also be removed.

In modified radical mastectomy, the surgeon removes the whole breast, most of the lymph nodes under the arm, and often the lining over the chest muscles. The smaller of the two chest muscles is also taken out to help in removing the lymph nodes.

In radical mastectomy (also called Halsted radical mastectomy), the surgeon removes the breast, the chest muscles, all of the lymph nodes under the arm, and some additional fat and skin. For many years, this operation was considered the standard one for women with breast cancer, but it is very rarely used today and only in cases of advanced cancer in which the cancer has spread to the chest muscles.

Breast reconstruction (surgery to rebuild a breast's shape) is often an option after mastectomy. Women considering reconstruction should discuss this with a plastic surgeon before having a mastectomy.

Here are some questions a woman may want to ask her doctor before having surgery:

• What kinds of surgery can I consider? Which operation do you recommend for me?
• Is breast-sparing surgery followed by radiation therapy an option for me?
• Do I need my lymph nodes removed? How many? Why?
• How will I feel after the operation? ? 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?
• When can I get back to my normal activities?

Radiation therapy (also called radiotherapy) is the use of high-energy rays to kill cancer cells and stop them from growing. The rays may come from radioactive material outside the body and be directed at the breast by a machine (external radiation). The radiation can also come from radioactive material placed directly in the breast in thin plastic tubes (implant radiation). Some women receive both kinds of radiation therapy.

For external radiation therapy, patients go to the hospital or clinic each day. When this therapy follows breast-sparing surgery, the treatments are given 5 days a week for 5 to 6 weeks. At the end of that time, an extra "boost" of radiation is sometimes given to the place where the tumor was removed. The boost may be either external or internal (using an implant). Patients stay in the hospital for a short time for implant radiation.

Radiation therapy, alone or with chemotherapy or hormone therapy, is sometimes used before surgery to destroy cancer cells and shrink tumors. This approach is most often used in cases in which the breast tumor is large or not easily removed by surgery.

Before having radiation therapy, a patient may want to ask her doctor these questions:

• Why do I need this treatment?
• What are the risks and side effects of this treatment?
• When will the treatments begin? When will they end? ? How will I feel during therapy?
• What can I do to take care of myself during therapy?
• Can I continue my normal activities?
• How will my breast look afterward?
• What are the chances of the tumor coming back in my breast?

Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy for breast cancer is usually a combination of drugs. The drugs may be given by mouth or by injection. Either way, chemotherapy is a systemic therapy because the drugs enter the bloodstream and travel throughout the body.
Chemotherapy is given in cycles: a treatment period followed by a recovery period, then another treatment, and so on. Most patients have chemotherapy in an outpatient part of the hospital, at the doctor's office, or at home. Depending on which drugs are given and the woman's general health, however, she may need to stay in the hospital during her treatment.

Hormonal therapy is used to keep cancer cells from getting the hormones they need to grow. This treatment may include the use of drugs that change the way hormones work or surgery to remove the ovaries, which make female hormones. Like chemotherapy, hormonal therapy is a systemic treatment; it can affect cancer cells throughout the body.

Patients may want to ask these questions about chemotherapy or hormonal therapy:

• Why do I need this treatment?
• What drugs will I be taking? What will they do?
• Will I have side effects? What can I do about them?
• If I need hormonal treatment, which would be better for me, drugs or an operation?
• How long will I be on this treatment?

Treatment Choices

Treatment decisions are complex. They are often affected by the judgment of the doctor and by the desires of the patient.

A patient's treatment options depend on a number of factors. These factors include her age and menopausal status; her general health; the size, location, and stage of the tumor; whether the doctor can feel lymph nodes under her arm; and the size of her breast. Certain features of the tumor cells (such as whether they depend on hormones to grow) are also considered. The most important factor is the stage of the disease. The stage is based on the size of the tumor and whether the cancer has spread.

The following section contains brief descriptions of the stages of breast cancer and the treatments most often used for each stage. (Other treatments may sometimes be appropriate.)

• Stage 0 is sometimes called noninvasive carcinoma or carcinoma in situ. lobular carcinoma in situ, or LCIS, refers to abnormal cells in the lining of a lobule. These abnormal cells seldom become invasive cancer. However, their presence is a sign that a woman has an increased risk of developing breast cancer. This risk of cancer is increased for both breasts. Some women with LCIS may choose to take a medication called tamoxifen to try to prevent breast cancer, or they may take part in studies of other promising new preventive treatments. Others may not receive any treatment, but return to the doctor regularly for checkups. Still others may have surgery to remove both breasts to try to prevent cancer from developing. (In most cases, removal of underarm lymph nodes is not necessary.)
  Ductal carcinoma in situ, also called intraductal carcinoma or DCIS, refers to cancer cells in an area of abnormal tissue in the lining of a duct that have not invaded the surrounding breast tissue. If DCIS lesions are left untreated, over time cancer cells may break through the duct and spread to nearby tissue, becoming an invasive breast cancer. Patients with DCIS may have a mastectomy or may have breast-sparing surgery followed by radiation therapy. Underarm lymph nodes are not usually removed. Women with DCIS may want to talk with their doctors about the possible usefulness of treatment with tamoxifen.
• Stage I and stage II are early stages of breast cancer, but the cancer has invaded nearby tissue. Stage I means that cancer cells have not spread beyond the breast and the tumor is no more than about an inch across. Stage II means one of the following: the tumor in the breast is less than 1 inch across and the cancer has spread to the lymph nodes under the arm; the tumor is between 1 and 2 inches with or without spread to the lymph nodes under the arm; or the tumor is larger than 2 inches but has not spread to the lymph nodes under the arm.
  Women with early stage breast cancer may have breast-sparing surgery followed by radiation therapy as their primary local treatment, or they may have a mastectomy, with or without breast reconstruction (plastic surgery) to rebuild the breast. Sometimes radiation therapy is also given to the chest wall after mastectomy. These approaches are equally effective in treating early stage breast cancer. The choice of breast-sparing surgery or mastectomy depends mostly on the size and location of the tumor, the size of the woman's breast, certain features of the cancer, and how the woman feels about preserving her breast. With either approach, lymph nodes under the arm usually are removed.
  Many women with stage I and most with stage II breast cancer have chemotherapy and/or hormonal therapy in addition to surgery or surgery and radiation therapy. This added treatment is called adjuvant therapy. It is given to try to destroy any remaining cancer cells and prevent the cancer from recurring, or coming back.
• Stage III is also called locally advanced cancer. The tumor in the breast is large (more than 2 inches across), the cancer is extensive in the underarm lymph nodes, or it has spread to other lymph nodes or tissues near the breast. Inflammatory breast cancer is a type of locally advanced breast cancer.
  Patients with stage III breast cancer usually have both local treatment to remove or destroy the cancer in the breast and systemic treatment to stop the disease from spreading. The local treatment may be surgery and/or radiation therapy to the breast and underarm. The systemic treatment may be chemotherapy, hormonal therapy, or both; it may be given before or after the local treatment.
• Stage IV is metastatic cancer. The cancer has spread from the breast to other parts of the body.
  Women who have stage IV breast cancer receive chemotherapy and/or hormonal therapy to destroy cancer cells and control the disease. They may have surgery or radiation therapy to control the cancer in the breast. Radiation may also be useful to control tumors in other parts of the body.
• Recurrent cancer means the disease has come back in spite of the initial treatment. Even when a tumor in the breast seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained in the area after treatment or because the disease had already spread before treatment. Most recurrences appear within the first 2 or 3 years after treatment, but breast cancer can recur many years later.
• Cancer that returns only in the area of the surgery is called a local recurrence. If the disease returns in another part of the body, it is called metastatic breast cancer. The patient may have one type of treatment or a combination of treatments.

Side Effects of Treatment

It is hard to limit the effects of cancer treatment so that only cancer cells are removed or destroyed. Because healthy cells and tissues may also be damaged, treatment often causes unwanted side effects.

The side effects of cancer treatment are different for each person, and they may even be different from one treatment to the next. Doctors try to plan treatment to keep problems to a minimum. They also watch patients carefully so that they can help with any problems that occur.

Surgery

Surgery causes short-term pain and tenderness in the area of the operation, so women may need to talk with their doctor about which method of pain control would be appropriate. Any kind of surgery also carries a risk of infection, poor wound healing, bleeding, or a reaction to the anesthesia used in surgery. Women who experience any of these problems should tell their doctor or nurse right away.

Removal of a breast can cause a woman's weight to shift and be out of balance--especially if she has large breasts. This imbalance can cause discomfort in a woman's neck and back. Also, the skin in the breast area may be tight, and the muscles of the arm and shoulder may feel stiff. After a mastectomy, some women have some permanent loss of strength in these muscles, but for most women, reduced strength and limited movement are temporary. The doctor, nurse, or physical therapist can recommend exercises to help a woman regain movement and strength in her arm and shoulder.

Because nerves may be injured or cut during surgery, a woman may have numbness and tingling in the chest, underarm, shoulder, and arm. These feelings usually go away within a few weeks or months, but some women may have permanent numbness.

Removing the lymph nodes under the arm slows the flow of lymph. In some women, this fluid builds up in the arm and hand and causes swelling (lymphedema). Women need to protect the arm and hand on the treated side from injury, even long after surgery. They should ask the doctor how to handle any cuts, scratches, insect bites, or other injuries that may occur. Also, they should contact the doctor if an infection develops in the arm or hand.

Radiation Therapy

The radiation oncologist will explain the possible side effects of radiation therapy for breast cancer--including uncommon side effects that may involve the heart, lungs, and ribs. One of the common side effects is fatigue, especially in the later weeks of treatment and for sometime afterward. Resting is important, but doctors usually advise their patients to try to stay reasonably active, matching their activities to their energy level. It is also common for the skin in the treated area to become red, dry, tender, and itchy. Toward the end of treatment, the skin may become moist and "weepy." Exposing this area to air as much as possible will help the skin heal. Because bras and some types of clothing may rub the skin and cause irritation, patients may want to wear loose-fitting cotton clothes. Good skin care is important at this time, and patients should check with their doctor before using any deodorants, lotions, or creams on the treated area. These effects of radiation therapy on the skin are temporary, and the area gradually heals once treatment is over. However, there may be a permanent change in the color of the skin.

For most women, the breast will look and feel about the same after radiation therapy. Occasionally, the treated breast may be firmer. Also, it may be larger (due to fluid buildup) or smaller (because of tissue changes) than it was before. For some women, the breast skin is more sensitive after radiation treatment; for others, it is less sensitive.

Chemotherapy

The side effects of chemotherapy depend mainly on the drugs the patient receives. As with other types of treatment, side effects vary from person to person. In general, anticancer drugs affect rapidly dividing cells. These include blood cells, which fight infection, cause the blood to clot, and carry oxygen to all parts of the body. When blood cells are affected by anticancer drugs, patients are more likely to get infections, bruise or bleed easily, and may have less energy during treatment and for some time afterward. Cells in hair follicles and cells that line the digestive tract also divide rapidly. As a result of chemotherapy, patients may lose their hair and may have other side effects, such as loss of appetite, nausea, vomiting, diarrhea, or mouth sores. Many of these side effects can now be controlled, thanks to improvements in antiemetics (drugs that reduce or prevent vomiting) and other medications. Side effects generally are short-term problems. They gradually go away during the recovery part of the chemotherapy cycle or after the treatment is over.
With modern chemotherapy, long-term side effects are quite rare, but there have been cases in which the heart is weakened, and second cancers such as leukemia (cancer of the blood cells) have occurred. Also, some anticancer drugs can damage the ovaries. If the ovaries fail to produce hormones, the woman may have symptoms of menopause, such as hot flashes and vaginal dryness. Her periods may become irregular or may stop, and she may not be able to become pregnant. However, some women may still be able to get pregnant during treatment. Because the effects of chemotherapy on an unborn child are not known, it is important for a woman to talk to her doctor about birth control before treatment begins. After treatment, some women regain their ability to become pregnant, but in women over the age of 35 or 40, infertility is likely to be permanent.

Hormonal Therapy

Hormonal therapy can cause a number of side effects. They depend largely on the specific drug or type of treatment, and they vary from patient to patient. Tamoxifen is the most common hormonal treatment. This drug blocks the body's use of estrogen but does not stop estrogen production. Tamoxifen may cause hot flashes, vaginal discharge or irritation, and irregular periods. Any unusual bleeding should be reported to the doctor. Younger women taking tamoxifen may become pregnant more easily and should discuss birth control methods with their doctor.

Serious side effects of tamoxifen are rare, but this drug can cause blood clots in the veins, especially in the legs. In a very small number of women, tamoxifen has caused cancer of the lining of the uterus. The doctor may do a pelvic exam, as well as biopsies or other tests of the lining of the uterus, to monitor for this condition. (This does not apply to women who have had a hysterectomy, surgery to remove the uterus.)

Young women whose ovaries are removed to deprive the cancer cells of estrogen experience menopause immediately. The side effects they have are likely to be more severe than the effects of natural menopause.

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