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Florida Heart CPR*
Breast Cancer
4 hours
Edited and Co-authored by: Mary Farrell, RN, MSN/Ed.
Objectives
After completing this activity the participant will be able to:
A. Define Breast Cancer in its multiple forms
B. Diagnose the disease and the stages a patient goes through
C. Demonstrate knowledge about available treatments
D. Describe pre and post surgical options including breast reconstruction
E. Articulate preventative measures
Diagnosis:
A diagnosis is the identification of a medical condition based on what is found when
certain characteristics of the condition are closely examined. Establishing the diagnosis
of a breast abnormality involves several important steps.

Physical Examination
Women themselves first notice most changes that occur in the breast. A woman who
practices regular breast self examination [BSE], is very familiar with the look and feel of
her breasts, and will more than likely notice a change that might indicate a problem. It is
important to realize that even a healthy breast will undergo certain changes over time,
and that what one is feeling may be a variation of normal breast anatomy. Most
irregularities that form in the breast are not cancer, and most of the diagnoses that are
made identify relatively normal conditions such as benign tumors, cysts or calcifications
that usually require no treatment.
When a lump, also called a mass or lesion, becomes large enough to feel, or palpate, it
is said to be palpable. Conversely, a suspicious area that is too small to feel is said to
be non-palpable. If the patient discovers something that the patient thinks may be a
change in the patient's breast anatomy, the next step is to have the patient's breasts
examined by the patient's gynecologist or internist.
The physician may want the patient to see a surgeon who specializes in breast cancer
and has the necessary expertise to make a reliable diagnosis of any unusual condition.
The surgeon may conclude that the patient's condition constitutes one of several natural
changes the breast undergoes over time and may recommend only follow-up. He or she
will recommend that the patient continue observing the patient's breasts by practicing
regular BSE and having regular clinical breast exams.
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The physician may suspect that an abnormal area is nothing more than a liquid-filled
lump or mass called a cyst and attempt to aspirate it by inserting a very thin needle into
the abnormal area. If it is indeed a cyst, aspiration will remove the fluid and the cyst will
collapse. The vast majority of cysts are benign and the reason they are aspirated is so
no further investigation to confirm their diagnosis is necessary. If the cyst does not
collapse entirely, or if the fluid is bloody, the aspirated fluid will be examined
microscopically by a cytopathologist (a pathologist who specializes in cytology, the
study of cells) to assess the nature of any cells present. Likewise, if the abnormal area
turns out to be solid, the aspirate may contain cells that can also be evaluated
microscopically. Only if the surgeon concludes that the patient's condition is suspicious
and requires further investigation, will he or she then recommend one or more
diagnostic procedures.

Mammography
A mammogram is an X-ray picture of the breast. With today’s advanced state-of-the-art
technology, mammograms require less radiation and are more sensitive and informative
than ever before. Surgeons can tell a great deal about what’s going on inside the breast
by reviewing the results of a mammogram and consulting with the radiologist who
interprets it. A radiologist is a specialist in the use of X-ray technology to visualize
certain parts of the human body. When the patient gets a mammogram, the patient
should make sure that the American College of Radiology has accredited the radiology
equipment being used.
Mammography is the relatively painless procedure that is performed by a specially
trained radiology technologist who produces a mammogram. He or she will guide the
patient through the steps of the procedure and can answer many of the questions the
patient may have about the procedure itself. The patient should not hesitate to express
feelings of discomfort to the technologist performing the mammography, or ask to speak
to the radiologist if the technologist is unable to answer questions to the patient's
satisfaction.
The technologist will perform the mammography by compressing the patient's breast
between two plates attached to a specially designed X-ray machine. The breast is then
"photographed" from two separate angles and the results are examined by the
radiologist. Any discomfort the patient may experience is most likely the result of
pressure exerted on the patient's breast by the plates. This is necessary to achieve the
highest possible detail while also minimizing radiation exposure. Some women are
concerned about exposure during mammography, but studies have shown that the risks
of exposure to radiation with state-of-the-art mammography equipment are minimal and
are far outweighed by the benefits of a thorough procedure.
The results of the mammogram will show the normal features of the breast, and may
reveal suspicious areas that require further investigation. Even if the results of the
mammogram are not suspicious, the patient's surgeon may recommend further
investigation based solely on the physical examination, as a small percentage of
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cancers are undetected by mammography. Occasionally women who undergo
mammography require magnification or compression views. These magnification views
enable the radiologist to better view tiny calcium deposits called micro calcifications or
small masses that are undetectable during a clinical breast examination. (No one knows
why these calcifications form, but we do know they are not the result of calcium in the
diet, a common misconception.) Often, a magnified or compression view of a suspicious
area eliminates it as an area of concern and the radiologist recommends only follow-up.
Sometimes, he or she may recommend a follow-up mammogram in several months to
make sure that the area is not changing.

Ultrasound
Ultrasound, also called sonography, is a procedure commonly used during pregnancy,
but it is also used frequently to distinguish a liquid-filled cyst (fluid-filled mass) from a
solid mass in the breast. The ultrasound is performed by covering the breast with jelly
and sliding an instrument called a transducer across its surface. The transducer
produces sound waves that will pass through a cyst or will bounce off a solid tumor,
creating highly distinct images on a screen. If a mass in the patient's breast turns out to
be a cyst, aspiration or observation may be appropriate.
If the mass turns out to be solid, a biopsy might be necessary. A biopsy is a procedure
that removes a sample of abnormal tissue or cells from the breast so that it can be
examined under a microscope by a pathologist for analysis and diagnosis. Pathologists
are trained to identify the nature of the tissue or cells. If a pathologist determines that
the tissue or cells are benign (i.e., a benign tumor, cyst or calcification) then the patient
does not have cancer, and regular follow-up may be all that is recommended.
Cells that are considered benign, but not completely normal, may indicate a condition
that, while not cancerous, puts the patient at increased risk for cancer. Atypical
hyperplasia or hyperplasia with atypia is such a condition. The breast tissue is
determined to have certain abnormal changes. While these changes are not cancerous,
they do increase the chances that cancer will develop. For this reason, women with
atypical hyperplasia are recommended to have more frequent clinical breast exams and
mammograms.
If the cells turn out to be malignant (cancer), the patient's condition will be diagnosed as
cancer and the patient's surgeon will discuss the various treatment options with the
patient.

Biopsy Procedures
The patient's surgeon will determine what type of biopsy is needed. The type of biopsy
depends on whether the suspicious area is palpable (can be felt), such as a mass or
thickening. Non-palpable findings (cannot be felt), such as micro-calcifications, a very
small mass, or vague density that have shown up only on a mammogram also require a
biopsy.
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We begin with the kind of biopsy required when a suspicious area is palpable.

Fine Needle Aspiration Biopsy
The physician - a gynecologist, a surgeon, or in some cases a pathologist - inserts a
very thin needle into the suspicious area of the breast. This is called aspiration. A local
anesthetic may be given to numb the skin. If the suspicious area is a cyst, it will yield
fluid and the cyst will collapse. If the cyst completely collapses, the fluid is discarded. If
the suspicious area is solid, the aspirate usually contains cells that the pathologist can
examine microscopically. Even if no malignant cells are found, a surgical biopsy may
still be necessary as cancer cells may exist in tissue not sampled by the needle. If
malignant cells are found, however, definitive treatment planning can begin. The
patient's surgeon will recommend a course of action.
A Word About Needle Biopsies

Core Needle Aspiration Biopsy
This process is similar to the fine needle aspiration biopsy described above, but a larger
needle is used and fragments of abnormal tissue, not just cells, can be removed. When
these tissue samples are examined microscopically by the pathologist, a definitive
diagnosis can usually be made.
Both types of needle biopsy can be performed in an office setting.

Excisional Biopsy
Also known as a surgical or open biopsy, the purpose of the excisional biopsy is to
remove the entire suspicious mass plus a rim of tissue surrounding the mass. The
tissue that is removed is then sent to the pathologist, who determines if it is benign or
malignant.

Incisional Biopsy
An incisional biopsy (another kind of surgical or open biopsy) is different from the
excisional biopsy because the surgeon does not remove the entire mass. The usual
reason an incisional biopsy is performed is that the mass is very large. A wedge of
tissue is removed and sent to the pathologist for examination. This procedure is
infrequently performed.
A Word About Surgical or Open Biopsies
Surgical biopsies are ambulatory or day surgery procedures, performed on an
outpatient basis. The patient will be given a local anesthetic in the area of the breast
and will not feel any pain during the procedure.
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When a suspicious area is non-palpable, one of the following procedures may be
recommended.



Ultrasound Guided Needle Biopsy,
Stereotactic Fine Needle Aspiration Biopsy, or
Stereotactic Core Needle Aspiration Biopsy
Since some non-palpable lesions can be visualized sonographically, using ultrasound,
but not necessarily using mammography, some needle biopsies are performed under
sonographic guidance. Other biopsies are performed using a special computerized
mammography machine.
A radiologist using this special computerized mammography machine, called a
stereotactic biopsy unit, inserts a fine needle or large core needle under the guidance of
the mammogram into the area of suspicion. A sample of this area is taken through the
needle. In the hands of an expert radiologist, the stereotactic technique is extremely
accurate at pinpointing mammographically-detected suspicious areas. The pathologist
examines the sample and makes the diagnosis so treatment planning can begin. A
surgical biopsy is sometimes recommended after stereotactic biopsy in cases where the
tissue obtained is not adequate to confirm either a cancer diagnosis or a benign lesion.
A six-month mammogram is often recommended for follow-up of a benign stereotactic
biopsy finding to assure that no changes have occurred.

Needle Localization
This procedure is used when the abnormality in the breast is not palpable, yet the
mammogram results are suspicious and require a surgical biopsy. If the surgeon
recommends an excisional biopsy to remove the non-palpable area of suspicion, then,
using ultrasound or mammography, the radiologist inserts a thin needle into the breast
before surgery that will guide the surgeon in locating the suspicious area for removal.
Needle localization is also called pre-operative needle localization.
An X-ray is performed on the piece of breast tissue obtained during surgery to confirm
that the suspicious area has been removed.

The Role of the Pathologist
The pathologist is a specialist trained to examine tissues and cells. The surgeon will
submit the patient’s excised, incised, or aspirated breast tissue to the pathologist along
with the specific studies the surgeon requests the pathologist to perform which include
establishing the histologic diagnosis, size of tumor, presence or absence of cancer in
surgical margins, stage of cancer, presence of hormone receptors, blood vessel
invasion, and lymph node status. The data collected by the pathologist will be used by
the surgeon to guide the patient in selecting the best primary and adjunct therapies,
estimate the patient’s prognosis, and assess outcomes.
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To understand breast cancer, imagine a bunch of grapes. The stem and its branches
represent the ductal system, and the grapes represent the lobules. When a cancer is
seen only in the ducts, we call it ductal; and when it occurs only in the lobules, we call it
lobular. When the tumor is confined to the ducts or lobules, we call it in situ; but, when
the cancer breaks out of the ducts or lobules and extends into the adjacent breast
tissue, we consider it to be invasive or infiltrating. This does not mean that the cancer
has spread beyond the breast.
Carcinoma in Situ and Invasive/Infiltrating Cancer
The earliest stage of breast cancer is called ductal carcinoma in situ (DCIS). With
current diagnostic techniques, this early stage is diagnosed frequently. Carcinoma in
situ may also develop in the lobule - lobular carcinoma in situ (LCIS). LCIS, unlike
DCIS, is not considered a cancer, despite its name. Instead, it is viewed as an indication
of increased risk, sometimes called a marker, for the subsequent development of
invasive cancer. The cancer that may develop can arise in either breast and may not
appear for 20 years, if ever.
The most common cancer of the breast is infiltrating ductal carcinoma. This cancer not
only invades various breast structures, but also may spread to the lymph nodes under
the arms (called axillary lymph nodes) and to other organs. Microscopically, the
pathologist recognizes different structural patterns of cancer cell growth and calls these
by different names. Some of these patterns are more aggressive than others, and it is
important to identify them because they help predict the future behavior of the cancer,
also called the prognosis. The pathologist describes many characteristics of the tumor:
its overall size, the pattern and features of the cancer cells, the extent of their deviation
from "normal" and the extent of invasion.
The pathologist also examines the axillary lymph nodes to determine whether they
contain cancer cells. These findings provide the most important information to predict
prognosis. Other tests may be useful for diagnosis, selection of treatment, or for
prognosis- for example, estrogen and progesterone receptor assays, DNA and S phase
analysis, flow cytometry, and search for tumor oncogenes. They are utilized in all cases
of breast cancer, and the results are included in the pathologist’s final report. The
patient's doctor will be able to explain to the patient the significance of these tests as
they pertain to the patient.
Spreading and Metastases
The danger of breast cancer is its ability to spread to the lymph nodes under the arms
or to other parts of the body. Lymph nodes are a series of glands that are linked
throughout the body (the lymphatic system), which drain waste from the blood and
secrete important components of the immune system into the blood stream. Lymph
nodes located under the arm (axilla) are called axillary nodes, and the removal of these
nodes is called an axillary dissection. When cancer spreads to the lymph nodes or to
other parts of the body this is called metastasis.
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The Stages of Breast Cancer
Stage is important in predicting the likelihood of distant spread or metastasis. Stage
also influences treatment planning and determines prognosis. As stage of cancer
increases, the risk of metastasis increases. Depending on the patient's stage, the
patient's physician may advise various tests such as X-rays, bone scans, and CT scans
to determine the presence or absence of measurable metastasis. Stage and presence
of metastases will influence treatment. Staging of a breast cancer occurs after the
pathologist examines the surgical sample. To make this process easier medical science
has devised a system of staging called TNM (T = tumor, N = node, M = metastasis).
Stage In situ - Ductal Carcinoma In situ or Lobular Carcinoma In situ, or Paget’s
Disease of the nipple.
Stage 1 - The tumor is equal to or smaller than 2 centimeters. There are no axillary
lymph nodes positive for cancer, and there is no evidence of distant metastasis.
Stage 2 - The tumor is over 2 centimeters but not more than 5 centimeters in size. The
axillary lymph nodes may or may not be positive for cancer. If a tumor is smaller than 2
centimeters, but the lymph nodes are positive, this would also be considered Stage 2.
Stage 3 - The tumor is larger than 5 centimeters with axillary lymph nodes positive for
cancer. It may extend into the pectoral muscle. In Stage 3, there is no distant
metastasis.
Stage 4 - If distant metastasis to other organs has occurred, the cancer is considered in
this stage regardless of the size of the tumor or the number of nodes involved.
The TNM system breaks down Stages 2 and 3 even further, but such distinctions are
not necessary for a basic understanding of breast cancer staging. Early stage breast
cancer includes stages In situ, Stage 1, and Stage 2.
Important concepts to keep in mind as the patient consider treatment options is the
difference between local and systemic treatments. Local treatments are procedures
performed on the breast and surrounding areas, such as surgery and radiation therapy.
Systemic treatments, such as chemotherapy and hormone therapy, are used to treat
breast cancer cells that may have spread to other parts of the body. Local and systemic
treatments are often combined to ensure the best outcome possible, and the patient's
priorities are an essential part of making the best treatment choice.
Surgery
The first step in treating the most common types of breast cancer is surgery, and the
patient's first decision will probably include a fundamental choice between breast
conservation and removal of the breast. The surgical procedures are: lumpectomy (also
called wide excision or partial mastectomy) with sentinel lymph node mapping,
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lumpectomy with axillary lymph node dissection, total or simple mastectomy, and
modified radical mastectomy, which includes axillary dissection. Lumpectomy is
considered a partial mastectomy and conserves varying degrees of breast tissue. Total
mastectomy removes the entire breast. Modified radical mastectomy removes the entire
breast and some axillary lymph nodes.
Cancer cells from a primary tumor in the breast first drain through one or more sentinel
lymph node(s) before spreading to the other lymph nodes. Sentinel lymph node
mapping is conducted to spare the axillary lymph nodes and spare the patient the
resulting symptoms that accompany an axillary lymph node dissection. The sentinel
lymph node is identified after a dye is injected; the sentinel lymph node is the first to
pick up the blue dye. Studies have shown that when the sentinel node is negative, the
remaining nodes are usually negative. A positive result indicates the cancer is in the
sentinel lymph node(s) and may have spread to other nearby lymph nodes.
Before surgery, tests such as a chest X-ray, complete blood chemistry, and a urinalysis
must be performed.
Breast Conserving Treatment
If the patient's cancer is diagnosed at an early stage, a lumpectomy or wide excision
with axillary lymph node dissection may be offered as a treatment choice. The goal of
this surgery is to remove the entire lump and some normal tissue surrounding the lump,
but preserve the breast. Radiation therapy follows lumpectomy and axillary lymph node
dissection and is an integral part of breast conserving treatment. The two treatments
combined, surgery and radiation therapy, have proven to be as effective as the modified
radical mastectomy
Not all women, however, are candidates for breast conserving treatment; acceptable
cosmetic results may not be possible for women whose breast cancers are multicentric
(found in more than one area of the breast) or who have a large breast cancer and
relatively small breasts. Also, it is extremely important for candidates who choose breast
conservation to accept that radiation therapy is integral to successful treatment.
Willingness to accept radiation treatment following lumpectomy and axillary node
dissection, and an understanding that regular follow-up is a lifetime commitment, are
essential elements for making this choice.
Lumpectomy
The entire lump and some normal tissue surrounding the lump that has been surgically
removed is sent to the pathologist. A microscopic determination is made whether the
tissue surrounding the lump is free of tumor cells. This is called clear margins.
If the pathologist’s determination reveals that cancer has invaded the surrounding
tissue, the margins are not clear and more extensive surgery may be necessary.
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Axillary lymph node dissection
This surgery is performed after the lumpectomy and at the same time as a modified
radical mastectomy. It involves removing some of the lymph nodes that are found under
the arm. This procedure is important to help stage the breast cancer, which helps
determine treatment choices.
Total or simple mastectomy
This procedure removes the entire breast without axillary lymph nodes. This procedure
is used to treat ductal carcinoma in situ (DCIS) that is not suitable for breast conserving
surgery.
Modified Radical Mastectomy
Modified radical mastectomy is the most widely used surgical treatment for breast
cancer, and has proven to be an effective local treatment for cancers in all stages.
Since the entire breast and some axillary nodes are removed in this procedure, postoperative radiation therapy is usually not necessary.
Reconstructive surgery may begin immediately following either a total mastectomy or a
modified radical mastectomy, before the patient's surgeon closes the incision. Or the
patient may elect to wait a few months or years, or elect not to have reconstructive
surgery at all.
Making Choices
The choice that most often faces women is between breast conserving treatment and
modified radical mastectomy. Research involving thousands of women over many years
has shown that for women with early stage breast cancers, there is no difference in
survival if only the lump is removed followed by radiation therapy, saving the breast.
Sometimes breast cancers do recur in the lumpectomy breast, but mastectomy can be
performed at that time and most women will do as well as those who had mastectomy in
the first place.
If the patient is offered a choice between breast conserving treatment, lumpectomy with
axillary lymph node dissection plus radiation, or modified radical mastectomy, the
decision becomes a personal one. If the patient chooses a mastectomy, or the patient's
surgeon recommends that the patient have a mastectomy, then the patient may wish to
consider reconstructive surgery. Reconstruction can be performed immediately, it can
be delayed, or the patient may not wish to consider reconstruction at all.
It is important to remember that no decision must be made overnight. The patient needs
to give herself a chance to discuss these options with family members, with the patient's
physicians, and with friends. The patient may have additional questions and the patient
is urged to call the surgeon during the patient's decision-making process. Additional
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help is also available through the breast service nurse coordinator who can serve as a
liaison for questions to the patient's physician, can answer some questions directly and
can provide a wide variety of written material. They are always available to the patient
by telephone, and they can help the patient set up additional appointments with a
radiation therapist or plastic surgeon.
There are also excellent support organizations such as SHARE (Self-Help for Women
with Breast or Ovarian Cancer), made up of women who have been treated for breast
cancer. They are available to the patient by telephone and are listed at the end of this
guide. The patient does not have to face breast cancer treatment decisions alone.
After Surgery
After a Lumpectomy with Axillary Node Dissection
Lumpectomies with axillary node dissection are usually performed using a general
anesthetic. The patient is usually sent home the same or next day after the patient's
surgery, once the effects of the anesthetic have worn off. Most of the time a tube will be
in place under the patient's arm on the operated side to drain away any fluid that
collects there following axillary lymph node dissection. Simple instructions on how to
care for the drainage tube at home will be given to the patient and the patient's family
member or friend before the patient leaves the recovery area. This is done if the patient
is discharged the day of surgery, or in the patient's hospital room if the patient stays
overnight. If the patient needs extra help, arrangements can be made to have a visiting
nurse come to the patient's home.
The patient will receive an appointment to see the patient's surgeon within 7 to 10 days
after the surgery to remove the stitches and the drainage tube under the patient's arm.
At this visit the surgeon will advise the patient on appropriate arm and shoulder
exercises. Exercise usually begins after the drain is removed to reduce the chance of
lymphedema, a swelling of the arm.
After a Modified Radical Mastectomy
This surgery is performed using a general anesthetic. When the patient wakes up after
the patient's mastectomy the patient may experience some discomfort around the
patient's chest and under the patient's arm. The patient's doctor will order pain
medication that will control the patient's discomfort. Two drainage tubes will be in place
to drain fluids that may collect in the operative areas - one to drain the chest area and
the other to drain where the axillary lymph nodes were removed. Should the drainage
tube(s) not be removed during the patient's hospital stay, simple instructions on how to
care for the tubes at home will be given to the patient and a family member or friend
before the patient is discharged. The patient will be encouraged to get out of bed the
same day as surgery, as soon as the anesthetic has worn off, and at that time the
patient should be able to eat regular food. Expect to stay in the hospital for a few days,
but the trend is for shorter hospital stays after a mastectomy.
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Radiation Therapy
Radiation therapy is an integral part of breast conserving treatment, but is rarely used
when mastectomy has been performed. It is a local treatment, aimed solely at
decreasing the likelihood of breast cancer recurring in the operated breast or chest wall
region.
If radiation therapy is planned, the treatment usually begins about two to three weeks
after surgery and lasts approximately six weeks. If chemotherapy is recommended,
radiation treatments may be delayed until the completion of chemotherapy, or may be
given at the same time as chemotherapy. A precise, individualized treatment plan will
be developed for the patient by a radiation oncologist using a special machine called a
simulator. A radiotherapy technologist under supervision administers treatment by the
radiation oncologist. Initially, the entire breast is treated once a day, five days a week.
The amount of radiation that is used is based upon the size and shape of the breast and
where the cancer was located. Toward the end of the treatment period the radiation is
focused on the smaller area of the breast where the tumor was located. This is called a
boost.
Potential side effects may include fatigue during and right after treatment, skin changes,
reddening like a sunburn, or swelling of the breast, but with the state-of-the-art
equipment used at today, these side effects are usually temporary and the final results
are very good.
Adjuvant Therapy
Even after surgery and radiation therapy have been completed, we know that it is
possible for microscopic breast cancer cells to have spread beyond the breast and
lymph nodes to other parts of the body. The presence of these microscopic breast
cancer cells is called micrometastasis because the quantity of cells is too small to be
detected by any current medical procedure. The way that we estimate the likelihood of
micrometastases is by determining the size of the tumor, the presence or absence of
positive axillary lymph nodes, and the nuclear grade of the tumor (how abnormal the
cells look). Based on these characteristics, systemic adjuvant therapy may be
recommended.
Adjuvant therapy - therapy that is additional to other treatment, such as primary surgery
- may be in the form of hormone therapy, chemotherapy, or both.
Hormone Therapy
Much has been learned about the role of the hormone estrogen and progesterone in the
development, diagnosis, and treatment of breast cancer. Hormones are normal
chemicals the patient's body produces to stimulate various physiological processes in
the body. Hormones such as estrogen and progesterone may stimulate the growth of
breast cancer cells. Tests, which show that the patient's cancer cells are hormone-
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receptor-positive or hormone-receptor-negative may be helpful in determining the type
of treatment that is most, appropriate for the patient. In general, women who have gone
through menopause are more likely to have cells that are hormone-receptor positive
and more likely to have hormone therapy recommended; premenopausal women are
more likely to have hormone-receptor negative cancer cells.
Hormone Therapy is a systemic treatment for breast cancer that keeps the cells from
growing and multiplying. It accomplishes this by blocking the ability of cancer cells to
bind with estrogen or progesterone, which certain cancer cells, need in order to grow.
As stated above, hormone therapy is usually recommended when the cancerous tissue
has tested hormone-receptor-positive.
Chemotherapy
Chemotherapy is the use of drugs to provide systemic treatment, which destroys cancer
cells throughout the body. In the treatment of breast cancer, it is administered in varying
doses through the veins or by mouth. It is usually administered after surgery, and the
doses, or courses, may be given over an average period of six months. If the patient's
treatment includes radiation therapy, chemotherapy may be recommended before, after,
or at the same time. Whether and when the patient undergoes chemotherapy will
depend on the stage of the patient's cancer, and, to some degree, on the patient's age
and other factors. In some cases, it is used to shrink a cancerous tumor before surgery,
so that the tumor can be removed more easily. The physician who determines what type
of chemotherapy the patient should have, and the dosage, is called a medical
oncologist.
Many of the potential side effects one associates with chemotherapy affect some people
more than others. Common ones hair loss, weight loss, fatigue, nausea and vomiting are not always as severe as they once were, and, in some cases, hair loss and weight
gain do not even occur. Hair loss can be particularly traumatic for women. It will always
grow back. And if the patient gains weight, the patient's weight will usually return to
normal after the treatment. To deal with the fatigue, the patient will simply have to take it
easy for a while and, whenever possible, let others take on some of the patient's
responsibilities. Although most women are especially fearful of nausea and vomiting,
the most up-to-date anti-nausea medication is extremely effective. The patient's
oncologist can usually tell the patient what to expect, and will work with the patient to
minimize these side effects. Most women are able to continue working while receiving
chemotherapy.
Reconstructive surgery may begin immediately after a mastectomy is performed,
months or years afterward, or not at all. In some cases the patient's surgeon may
recommend that the patient wait a period of time before beginning reconstruction, but in
most cases the timing is up to the patient. If the patient does have a mastectomy, and
the patient chooses reconstruction, several very successful procedures are available for
the patient to choose from. All of these procedures have inherent advantages, and the
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patient should weigh the particular merits of each as the patient considers breast
reconstruction.
Making a Decision
There is absolutely no urgency for making a decision about breast reconstruction. From
a medical standpoint it does not matter when the patient does it, or even if the patient
does it. Many women do not want to contend with additional procedures of any kind
immediately following a mastectomy. Others feel that additional surgery to reconstruct
the breast will help them psychologically.
In any case, the patient's surgeon can refer the patient to several plastic surgeons who
will advise the patient regarding the types of reconstructive surgery available, and,
perhaps, make specific recommendations based on the patient's particular size, shape,
and desired look. Reconstructive surgery is always performed by a plastic surgeon, and
many specialize in breast reconstruction.
Surgical Implants
The most common method of breast reconstruction involves a surgical implant, just like
the ones used for cosmetic breast augmentation. The patient has a choice between
silicone and saline breast implants. After a ten year study, the FDA lifted the moratorium
on silicone implants in 2006 giving the patient another breast reconstructive option. Both
implants require insertion of a tissue expander to expand the surrounding tissue until
the area is large enough to accommodate the size of the implant selected by the
patient. Both the silicone and saline breast implants have the same complications which
include contracture of the breast capsule, breast pain, change in nipple sensation, and
rupture of the implant which requires additional surgery.
If the patient chooses breast reconstruction immediately following the patient's
mastectomy, the patient's plastic surgeon, working with the patient's breast surgeon, will
more than likely start the process by inserting a tissue expander before the mastectomy
incision is closed. This is a saline implant with a silicone covering that allows the normal
tissue surrounding the patient's breast to expand gradually over a period of 8 to 10
weeks before a permanent implant is put in place. This will not affect the patient's
recovery period, and the drains and side effects of the patient's mastectomy will be
much as described previously. In this case, a permanent implant that matches the size
and shape of the unaffected breast can be positioned as soon as the surrounding tissue
has sufficiently expanded, usually as an outpatient procedure. Some women use this as
an opportunity to expand or decrease the size of both breasts and elect cosmetic
surgery of the other breast to achieve symmetry.
Who is in Charge?
By the time the patient has completed treatment, the patient has come in contact with
several specialists who may continue to be involved in some facet of the patient's care.
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Breast Cancer
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The patient has been in contact with the patient's surgeon, radiation oncologist, and
medical oncologist. For follow-up, some women choose their surgeon, some their
medical oncologist, but, in any case, a breast specialist should be in charge of the
patient's ongoing breast care. Regular breast follow-up requires a lifetime commitment.
The patient should continue to see the patient's practitioner for general care and for
other health problems. Many women also continue to see their gynecologists.
Breast Self-Examination (BSE)
Breast self-examination should become a part of the patient's regular routine. If the
patient is still menstruating, it should be performed once a month, three or four days
after the patient's period has ended. If the patient has already been through
menopause, or is experiencing irregular periods, the patient should do a breast
examination once a month, coinciding with some other monthly routine so that the
patient won’t forget. The patient may even choose to mark her calendar for the first of
each month as a constant reminder.
If the patient hasn't done it in the past, the patient may wish to seek instructions from
her gynecologist or surgeon. The process is much the same after surgery as before for
women who have chosen breast conserving treatment. Women who have undergone
breast reconstruction should ask their surgeon how to distinguish suspicious areas that
need further investigation from small lumps or ridges that are the result of surgery.
Physical Examinations
The frequency of physical examinations, including clinical breast examinations, may
differ depending on the type of the patient's breast cancer or its stage at the time of
diagnosis. In some cases, the patient's surgeon will want to examine the patient about
every three months for the first year, three times a year for the next two years, and twice
a year thereafter. These follow-up intervals vary from surgeon to surgeon. In addition,
the patient should continue to see her gynecologist on a regular basis and should be
followed regularly by her internist or medical oncologist.
Mammograms
The patient should have a mammogram once a year of both breasts if the patient had a
lumpectomy, or of the unaffected breast if the patient had a mastectomy. In some
cases, a physician may recommend a mammogram more than once a year on a breast
that has undergone breast-conserving treatment. In any case, breast self-examination,
clinical breast exams, and mammography are essential parts of ongoing care.
Blood Tests
Certain blood tests are helpful in determining the patient's general state of health. Blood
chemistries are useful to determine the possibility of occurrence in the bones or liver.
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Breast Cancer
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Other blood tests, referred to as tumor marker tests, may be performed to determine the
possibility of recurrence.
Surveillance for Other Cancers
We urge the patient not to neglect the possibility of other cancers, such as uterine
(endometrial), ovarian, and colorectal cancer, where the patient's risk is increased
because of a personal history of breast cancer. Endometrial cancer, cancer of the lining
of the uterus - especially important to monitor if the patient is taking tamoxifen - requires
regular gynecological follow-up. Early detection is extremely effective against
endometrial and colorectal cancer. Please discuss cancer surveillance with the patient's
physician.
When a cancer has developed in the breast itself it is called a primary cancer. Any
subsequent breast cancer near the original finding is called a local recurrence.
Additional surgery and/or radiation therapy may then be recommended. If the patient
has local recurrence after breast conserving treatment, the breast may then be treated
by mastectomy. Studies have shown that women who choose breast-conserving
treatment first, and then have a mastectomy, will have the same long-term outcome. If
breast cancer cells are detected in other parts of the body, this is called metastasis
(distant recurrence). When this happens systemic chemotherapy and/or hormone
therapy are the treatments of choice.
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Breast Cancer
16
Florida Heart CPR*
Breast Cancer Assessment
1. Diagnosis may include:
a. Physical examination
b. Mammography or ultrasound
c. Biopsy procedures
d. All of the above
2. This process is similar to the fine needle aspiration biopsy, but a larger needle is
used and fragments of abnormal tissue, not just cells, can be removed.
a. Core Needle Aspiration Biopsy
b. Excisional Biopsy
c. Incisional Biopsy
d. None Of The Above
3. When a suspicious area is non-palpable, one of the following procedure(s) may
be recommended.
a. Ultrasound Guided Needle Biopsy
b. Stereotactic Fine Needle Aspiration Biopsy
c. Stereotactic Core Needle Aspiration Biopsy
d. A, B, and C
4. This specialist, using a special computerized mammography machine called a
stereotactic biopsy unit, inserts a fine needle or large core needle under the
guidance of the mammogram into the area of suspicion in order to take a sample.
a. Oncologist
b. Internist
c. Radiologist
d. Gynecologist
5. When a cancer is seen only in the ducts, we call it ductal; and when it occurs
only in the lobules, we call it lobular. When the tumor is confined to the ducts or
lobules, we call it _____; but, when the cancer breaks out of the ducts or lobules
and extends into the adjacent breast tissue, we consider it to be _________.
a. In situ; invasive or infiltrating
b. In situ; metastatic
c. Stationary; invasive or infiltrating
d. Stationary; metastatic
6. The earliest stage of breast cancer is called:
a. ductal carcinoma in situ (DCIS)
b. lobular carcinoma in situ (LCIS)
c. ductal lymphoma in stiu (DLIS)
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Breast Cancer
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d. lobular lymphoma in situ (LLIS)
7. These are a series of glands that are linked throughout the body, which drain
waste from the blood and secrete important components of the immune system
into the blood stream.
a. Lacteals
b. Lymph nodes
c. Lymphoid follicles
d. Venules
8. TNM is used in determining the stage of the cancer. This stands for
a. T=tumor, N= number, M= metastasis
b. T=tumor, N=node, M= movement
c. T=tumor, N=node, M= metastasis
d. T= tumor, N=number, M= metastasis
9. The first step in treating the most common types of breast cancer is:
a. Chemotherapy
b. Radiation
c. Hormone therapy
d. Surgery
10. By the time the patient has completed treatment, she has been in contact with
the patient's surgeon, radiation oncologist, and medical oncologist. For follow-up,
some women choose their surgeon, some their medical oncologist, but, in any
case, _______ should be in charge of the patient's ongoing breast care.
a. An oncologist
b. A breast specialist
c. A general practitioner
d. A gynecologist
Florida Heart CPR*
Breast Cancer