If you’ve been diagnosed with breast cancer, your mind is probably filled with questions about treatment. Perhaps you’ve heard about lumpectomy, but you question whether it’s the best treatment for you.
You’re not alone. Many women ask the same question. For decades, mastectomy has been the surgery of choice. But, recent research shows that lumpectomy combined with radiation, is as safe and effective as mastectomy for invasive breast cancer.
Oncology nurse Rosalind Benedet and radiation oncologist Mark Rounsaville, M.D., have worked with hundreds of breast cancer patients, and understand your concerns. In Understanding Lumpectomy, they draw from years of experience to answer your many questions. Among the topics they cover:
• How breast cancer is diagnosed and staged
• Understanding when lumpectomy is an option
• How a lumpectomy procedure is performed
• Radiation therapy—how it works and what to expect
• When chemotherapy or hormonal therapy is needed
• Coping emotionally
• Exercises to regain arm mobility
• Preventing lymphedema—arm swelling
• Optimum nutrition for healing
Your Guide to Lumpectomy . . . from Diagnosis to Recovery
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About the Author
Read an Excerpt
Understanding Breast Cancer
If you're like most women, you've always thought of breast cancer as something that happens to someone else. Until now. If you or a loved one has been diagnosed with breast cancer, you already know the emotional impact of a cancer diagnosis. And you are not alone. Approximately 200,000 American women are diagnosed with breast cancer each year, making it the most common cancer among women.
There is cause for optimism. Breast cancer is one of the most treatable cancers. The survival rate for women with localized, nonmetastatic breast cancer has improved in recent years. The five-year survival rate, which was 72 percent in the 1940s, has increased to 96 percent today. Currently, over 2 million breast cancer survivors live in America.
There are other reasons to be hopeful. Breast cancer treatment has come a long way. Most women no longer have to lose their breast since breast-conserving surgery, or lumpectomy, followed by radiation therapy, has been proven as safe and effective as mastectomy. And the delivery of other treatments, radiation and chemotherapy, has greatly improved. In short, breast cancer treatments are less invasive and easier to tolerate, and physical recovery is faster.
What Is Cancer?
Cancer is a collection of cells that are on a path of uncontrollable growth. Cancer starts when normal cells are damaged, and the genes change, or mutate. Unlike normal cells, which divide a limited number of times before they die, these mutated cells have become "immortal"— they never stop dividing. One cell divides into two, two divide into four, and so on, and this mass of cells forms a tumor. This process takes a while. A one-centimeter breast tumor, 3/8th of an inch, and containing about 100 billion cells, takes seven to ten years to form.
Cancer cells have other unique abilities. Individual cells can break off from the main tumor and travel throughout the body by way of our blood vessels and lymph vessels. As a result, tumors may form in distant organs.
Symptoms of Breast Cancer
Breast cancer symptoms may show up in a number of ways. In general, breast cancer causes a change in the breast that is persistent and gets worse over time. Sometimes the change can be detected on mammogram, sometimes it can be felt, and sometimes it can be seen.
Lump in the Breast
Sometimes breast cancer is found by feeling, or palpating, a lump or thickening in the breast or underarm area. It is usually solitary lump, found in one breast, and it is distinctive — it's usually harder than the surrounding breast tissue. The lump may have been growing for several years before it became large enough for you to notice it. Most of the time it does not hurt, although about 8 percent of the time, there is some pain, discomfort, or a strange feeling associated with the lump.
Although a breast cancer lump typically feels hard, sometimes a cancerous lump can be soft. It is important to know that one cannot tell whether a lump is cancerous simply by touch. Even the most experienced doctor will need to investigate further.
Visible Changes in the Breast
Sometimes breast cancer symptoms are visible. These visible changes persist and generally worsen over time. Some of the visible changes that may indicate breast cancer are:
Persistent and spontaneous nipple discharge
A change in the contour of the breast, such as a dimple or a retracted nipple (nipple is pulled inward)
An enlarged breast that looks red and feels painful and hot (inflammatory breast cancer)
A persistent sore on the nipple or areola (Paget's disease)
Risk Factors for Breast Cancer
When a woman is diagnosed with breast cancer, one of her first questions may be, "What could have caused this?" Many women have a sense that something — perhaps something they did — caused the cancer. Please remember that the exact causes of breast cancer are unknown. And most importantly, if you have been diagnosed with breast cancer, don't blame yourself. You are not at fault.
Breast cancer is considered a "multifactorial disease"— many factors interact with each other in ways that we don't yet understand. A few factors are known to increase a woman's risk.
The most significant risk factor for breast cancer is age. Clearly, it is a risk factor that we can do nothing about. As we age, our risk increases for cancer and most other diseases as well. Why? Our immune systems weaken as we get older, and we are more susceptible to disease. Approximately 18 percent of women diagnosed with breast cancer are in their forties. About 77 percent of women diagnosed are more than fifty years old.
Childbirth and Menstrual History
Childbirth and menstrual history have a sight impact on a woman's risk for breast cancer. There may be an association between the number of times a woman ovulates during her life and the risk of breast cancer: women who have ovulated more have a higher risk for breast cancer. This would include women who had their first period before age eleven or who never had children. It also includes women who enter menopause later, after age fifty-five; they are at slightly increased risk because they have had more exposure to the hormones estrogen and progesterone.
Pregnancy and nursing decrease a woman's risk of breast cancer. Why? Because breast cells are not fully developed until they lactate, or produce milk. If the breast has fully matured, it is less susceptible to the changes that may promote breast cancer.
High doses of radiation to the chest area, particularly during adolescence, increase the risk of breast cancer. For example, young girls who were treated with radiation therapy for Hodgkin's disease, a cancer of the lymph nodes, have a significant risk as they age. You may be relieved to hear that the radiation from modern mammography probably does not increase the risk of breast cancer. The dose of radiation is very small; mammograms are given infrequently, once or twice a year; and they are started at age forty, when breast tissue is less sensitive to radiation.
Over the years, studies have suggested that drinking alcoholic beverages increases a woman's risk, but the studies were too small to identify the amount of alcohol that increased risk. Does an occasional drink increase a woman's risk?
In 2002, British researchers analyzed 80 percent of the worldwide studies on alcohol consumption and breast cancer and found that women who consumed alcoholic beverages daily did have an increase in risk. As the number of daily drinks increased, the more the risk increased. Women who consumed more than four drinks a day had a significant increase in risk; women who had only one drink a day had a small increase in risk.
Nutrition and Exercise
To what extent diet affects one's risk for breast cancer is somewhat controversial. Many studies from around the globe disagree. For example, out of twelve studies that examined diet and its association with breast cancer risk, five studies showed an association between a high fat diet and breast cancer; but four studies showed no such association.
Similarly, several studies looked at the role of vitamins in the diet. Two studies found that women who ate foods with the highest amounts of vitamin C and beta-carotene (vitamin A from vegetables) had a decreased risk for breast cancer. A third study found no association with risk.
A cancer diagnosis feels like the world as we know it has just fallen apart, but it also bring us deep learning.
— Karen, 46
Is there an association between exercise and risk of breast cancer? Some newer studies suggest that strenuous exercise in one's youth may provide life-long protection against breast cancer. Exercising as an adult may provide additional protection.
Environmental and Household Chemicals
Breast cancer advocacy groups and consumer groups have raised concerns about the possible link between breast cancer and environmental toxins and household chemicals. Laboratory studies offer evidence that such links do exist. On the other hand, current research does not show a clear link between breast cancer risk and pollutants such as DDE, a pesticide, and PCBs, which are used in hundreds of products including paints, plastics, and rubber.
Still, an estimated 85,000 synthetic chemicals are registered for use today in the USA, and more than 90 percent of these chemicals have never been tested for their effect on human health.
Hormone Replacement Therapy (HRT)
Taking estrogen and progesterone for hormone replacement therapy (HRT) slightly increases a woman's risk of breast cancer. Only since 2002, when the results of a landmark clinical trial were published, can this statement be made with assurance.
The National Institute of Health initiated the Women's Health Initiative (WHI), a large, well-designed clinical trial to test the risks and benefits of hormone replacement therapy. The WHI study found that during one year's time, among women taking both estrogen and progesterone, 38 out of every 10,000 women developed breast cancers. This compares to 30 women who were taking the placebo.
Cancer taught me that life is precious and that I should enjoy each day to the fullest.
— Vivian, 55
What about the women who took estrogen alone? After five years, the study found no evidence of an increase risk in breast cancer in women taking estrogen alone.
If you are diagnosed with invasive breast cancer and are taking HRT or estrogen alone, you need to bring this is to the attention of your doctor. You'll probably be advised to stop taking hormone supplement, because most breast cancers seem to be stimulated by estrogen and progesterone.
Your doctor may advise you to decrease it gradually to help your body adjust. This regimen works well for many women: Take your usual dose every other day, for one week. Then take your dose every third day for one week. Continue adding a day between doses every week until you are no longer taking HRT. If you wear a patch, cut it half for one week and then cut that in half for another week.
A final interesting note: Other studies have demonstrated that women who were on HRT when their breast cancer was diagnosed had mortality rates 10 and 15 percent lower than women who were not on HRT when diagnosed. Much more research is needed on the risks and benefits of hormone replacement therapy.
A small percentage of breast cancers — approximately 10 percent — are related to heredity. How is this determined? In 1994, genetic researcher Dr. Mary-Claire King discovered two genes that she called BRCA1 and BRCA2. Women who carry a mutated form of either of these genes have a 35 to 87 percent risk of developing breast cancer by age 70. These women also have a 17 to 60 percent risk for developing ovarian cancer.
How can you determine whether you have the inherited type of breast cancer? When a family carries the genetic mutation, a pattern emerges — multiple relatives in multiple generations have breast and ovarian cancer. You need to look at your father's side of the family, as well as your mother's. Specifically:
A number of women (and a few men) over several generations developed breast cancer.
With each generation, women tended to develop breast cancer at a younger age.
Some family members had breast cancers in both breasts.
Since BRCA1 & BRCA2 increase the risk of ovarian, prostate, and colon cancer, some family members also developed these as well.
Certain geographic areas and ethnic groups have a higher incidence of mutated BRCA1 or BRCA2. These include the areas of Iceland and Norway, and individuals of Eastern and Central European Jewish ancestry.
Experts think that about 25 percent of inherited breast cancers are not associated with mutation in BRCA1 or BRCA2. Research is ongoing to identify other genes that may be associated with breast cancer.
Consider Genetic Testing
If you think that you may have the inherited type of breast cancer, you may want to be tested. A commercial blood test has been developed for the presence of mutations on BRCA1 or BRCA2. If you test positive for a defect in BRCA1 or BRCA2, your daughter or other family members may choose to be tested. Remember that not everyone necessarily inherits the gene; each person has a 50 percent chance of inheriting it.
Talk to a Genetics Expert
Genetics counselors are most helpful to a family dealing with inherited breast cancer. These counselors are trained to help individuals decide whether to be tested, and to help them understand the test results. Genetics counselors are trained to help you and your family discuss the emotional issues that often arise, including fear, guilt, anger, and shame.
Genetics counselors can also answer practical questions about the cost of testing and whether insurance pays for it. They are also familiar with the ethical issues regarding patient confidentiality and the legal issues that pertain to a patient's right to health insurance.
Getting a Diagnosis
If you have discovered a lump in your breast, or if your radiologist has discovered something suspicious in a mammogram, you will need further testing. Of course, this is a stressful time, as you wait and wonder if you have cancer. This stress can be alleviated somewhat with education about what happens next — how breast cancer is ruled out or how it is diagnosed.
Diagnosing breast cancer involves several steps. The first step usually includes a breast examination by your health care provider. This examination is typically followed by imaging studies, such as a mammogram or an ultrasound or both, then a biopsy — a tissue sample. Waiting for appointments and test results can be anxiety producing, to say the least.
Keep in mind that most breast biopsies are negative — no cancer. And the days or weeks that pass before you get a definitive answer will not negatively affect your outcome if you are diagnosed with breast cancer. This period of waiting will not be time enough for the cancer to spread.
Nevertheless, most women would like their appointments and results as soon as possible. Generally, you can expedite the process by letting your concerns be known. When making appointments, let the office staff know that you are worried and want to be seen as soon as possible. And let your doctors know how you feel and ask their help in expediting the process.
Diagnostic Tests for Breast Cancer
A mammogram is an X-ray of the breast. A diagnostic bilateral mammogram is an X-ray of both breasts. About 80 to 90 percent of breast cancers can be seen on mammogram. About half of all breast cancers show up in the X-ray. Invasive breast cancer commonly appears on a mammogram as an irregularly-shaped, solid mass called a "speculated mass." Sometimes breast cancer can be felt as well. Early breast cancers appear on mammograms as a cluster of linear or branching calcifications (calcium deposits). These calcifications are too small to be felt by hand.
However, it is important to note that not all calcium deposits look suspicious. In fact, calcium deposits are a common and normal mammographic finding. Remember that cancer may cause calcium deposits, but calcium deposits do not cause cancer. So if your core biopsy demonstrates benign (non-cancerous) tissue, then any residual calcifications will not increase your risk of breast cancer.
How Reliable Are Mammograms?
You've probably heard by now that mammograms are not 100 percent reliable. Some women who have a normal mammogram may have a palpable lump or a change in the appearance of the breast that indicates breast cancer. Breast cancer may not be seen on a mammogram if your breast tissue is dense. The glandular tissue, the part of the breast that makes milk, is dense.
As women age, the glandular tissue shrinks and is replaced by fat. Mammograms are most sensitive after menopause, less sensitive during a woman's forties, and much less helpful in women under age forty. In addition, mammograms are not sensitive in women who are pregnant or breast-feeding.
Certain types of breast cancers are not typically found on mammogram. For example, invasive lobular cancer, inflammatory breast cancer, and Paget's disease usually do not show up on a mammogram.
An ultrasound uses high-frequency sound waves to evaluate the internal tissues of the breast. For this test, a radiologist and a technician apply a lubricant to your breast and slide an instrument, called a transducer, across your skin. The sound waves the transducer sends into your body bounce off the internal tissue, creating an image on a monitor.
An ultrasound determines weather the area of concern contains a discrete mass or normal breast tissue. If a mass is found, the ultrasound can determine if the mass is a fluid filled "simple cyst;" these are benign cysts. The test can also determine the lump is a "complex cyst," which contains fluid and solid particles, or whether it is a solid mass. In both these cases, a biopsy is the next step. The tissue must be sampled to determine whether it is cancerous. Remember, however, that not all solid lumps are cancerous.
Excerpted from "Understanding Lumpectomy"
Copyright © 2004 Rosalind Benedet.
Excerpted by permission of Addicus Books, Inc..
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Table of Contents
1 Understanding Breast Cancer,
2 Getting a Diagnosis,
3 Your Lumpectomy,
4 The Pathology Report,
5 Recovering from a Lumpectomy,
6 Exercise as Part of Recovery,
7 Chemotherapy and Hormonal Therapy,
8 Radiation Therapy,
9 Nutrition for Healing,
10 Coping Emotionally,
11 Understanding Lymphedema,
12 Follow-up Care,
About the Authors,