Breast Cancer Treatments

Lumpectomy is a type of breast cancer treatment in which your breast is preserved. For this reason it's called a breast conserving or breast preservation surgery. In a lumpectomy, the surgeon removes only the breast tumor and some surrounding normal tissue. Technically, a lumpectomy is a partial mastectomy, because part of the breast tissue is taken out. The amount of tissue taken varies from patient to patient.

What to Expect in a Lumpectomy

If your tumor cannot be seen or felt, the surgeon will call for a mammogram or ultrasound. These tests will help the surgeon locate and mark the tumor. The surgeon or a nurse may draw with a felt tip marker on your breast to show where the incision will be.

In cases where the tumor cannot be seen or felt, the surgeon may also use a technique called needle localization or wire localization. The surgeon will insert a thin, hollow needle into the breast. A mammogram is conducted to make sure the needle is positioned properly. If it is, a fine wire is threaded through the hollow needle to mark the area. The needle is removed, leaving the wire behind. The surgeon will use the wire as a guide to remove the tumor and surrounding tissue.

In the anesthesia room, a nurse will insert an intravenous infusion (IV) line into your hand or arm. It will be taped in place. This is not painful but may feel cold or uncomfortable. You'll be given relaxing medication through this IV line.

You will have a local anesthetic to numb the incision area. Some people get general anesthesia as well.

The actual surgery takes about 15-50 minutes. Most surgeons make curved incisions (like a smile or frown). This way, the incision follows the natural curve of your breast.

Sometimes it is necessary to insert a rubber tube called a drain into your breast area or armpit. This collects extra fluid that can build up in the space where the tumor was.

Lumpectomy Recovery

When the surgery is over, you'll be moved to a recovery room. Nurses will monitor your vital signs—your heart rate, body temperature and blood pressure. Usually you don't have to stay overnight in the hospital with a lumpectomy.

You may be given pain medication in the recovery room. You will have a prescription to take home with you. It's a good idea to get it filled on your way home. You might ask a friend or family member to get it filled for you as soon as you are home. You may not need the medication, but you should have it in case you do.

Before you leave, your surgeon or nurse will instruct you in caring for the lumpectomy bandage. Sometimes, you will need to do nothing to the bandage until your follow-up visit. If you have a drain in your armpit or breast area, it might be removed before you go home. Sometimes a drain stays in until the first follow-up visit with the doctor. This appointment is usually 1-2 weeks after surgery. In that case, you'll need to empty the fluid from the detachable drain bulb several times a day. You will need to record the amount of fluid in the bulb. Your surgical team will give you instructions on caring for the drain.

Most surgeons use stitches that dissolve over time. Some surgeons still use surgical staples. These are removed during your first follow-up visit.

You will need someone to drive you home from the hospital.

Once You're at Home

With your surgeon's permission, you will need to exercise the side where you had the lumpectomy. This will prevent stiffness in your arm or shoulder. Your surgeon or a nurse will show you these exercises. Generally, you will start on them the morning after surgery. Your surgical team will also tell you what signs of infection to look for in your incision.

You'll need to stay home and rest for a few days after your lumpectomy. Make sure to get enough rest so you can return to your normal routine. It is normal to feel fatigued after the procedure.

You may feel pain or numbness around the incision. Take pain medication, if needed, according to your doctor's directions.

Do not bathe until your doctor has removed your drains and/or sutures. Take sponge baths until then.

It's important to wear a good sports bra that provides support. Wear it both day and night for a while to restrict movement that could cause pain. If you have large breasts, you may want to sleep on the side not operated on and support your healing breast under a pillow.

When you've had a lumpectomy, your nerves will need to regrow. As they do, you might feel a crawling sensation. You may itch or be sensitive. You can take acetaminophen or NSAIDs like ibuprofen for relief.

Questions to Ask

Here are some questions to ask your surgeon as you plan for lumpectomy surgery:

• How many lumpectomies have you performed?
• What are the risks?
• How should I prepare in advance?
• How long does the surgery take?
• How much tissue will be removed?
• How will you decide how much tissue to remove?
• Will you remove any lymph nodes under my armpit?
• Will I have anesthesia? If so, what kind?
• Should I donate my own blood before surgery? Will I need blood transfusions?
• How will my breast look after the lumpectomy?
• Will I need to stay in the hospital overnight?
• How long is the recovery process? When can I resume my normal activities?
• What exercises do I need to do after surgery?
• What precautions should I follow once I go home?
• How much pain medication can I take?
• Will I be at risk for lymphedema after surgery?
• What signs of infection should I watch for?

Segmentectomy

A segmentectomy is similar to a lumpectomy. However, in a segmentectomy, more of the surrounding breast tissue is removed with the lump. Usually, some lymph nodes are also removed at the same time.

Who should not have it?

Radiotherapy is required after segmentectomy. For this reason, pregnant women and other people who can't tolerate radiation should not have segmentectomy.

What to Expect

After a segmentectomy, you should not do any moderate lifting for several days. Other activities may be restricted as well. You may be instructed to wear a well-fitting support bra both day and night for about a week after surgery. If you feel pain, it can usually be well- controlled with pain medication that your doctor gives you.

Radiation therapy starts four to six weeks after surgery. It continues for four to five weeks. The exact timing is different for each patient.

A mastectomy is a procedure where your entire breast (nipple, areola, lymph nodes, and some of the surrounding tissue) is removed. You may not realize that there are actually 6 different kinds of mastectomy:

• Simple (or total) mastectomy
• Radical mastectomy
• Modified radical mastectomy
• Partial mastectomy
• Subcutaneous (nipple sparing) mastectomy
• Skin sparing mastectomy

Simple (Total) Mastectomy

In some mastectomies, it's necessary to remove lymph nodes under your arms. This is called axillary lymph node dissection. However, in a simple mastectomy, usually no lymph nodes under your arms are removed. The only lymph nodes that are sometimes removed in a simple mastectomy are nodes that are located within the breast tissue itself. In addition, the surgeon removes no muscles from beneath your breast. This makes recovery a bit easier.

When is a Simple Mastectomy Called For?

Your doctor may recommend a simple mastectomy if you:

• Have many or large areas of ductal carcinoma in situ (DCIS); or
• Want a prophylactic mastectomy—in other words, one that prevents breast cancer from occurring in the future

Radical Mastectomy

This is the most extensive kind of mastectomy. In this procedure, the surgeon removes your whole breast. In addition, the surgeon removes:

• Three levels of your underarm lymph nodes
• The chest wall muscles under your breast

When is a Radical Mastectomy Called For?

Radical mastectomies were common in the past. However, today, a radical mastectomy is only recommended when the cancer has spread to your chest muscles. For most people, modified radical mastectomy is just as effective as radical mastectomy. However, it is less disfiguring.

Modified Radical Mastectomy

In this procedure, the surgeon removes both the breast itself and two levels of lymph nodes. This process is called axillary lymph node dissection. The surgeon removes no muscles from under your breast.

When is a Modified Radical Mastectomy Called For?

If you have invasive breast cancer and are going to have a mastectomy, your surgeon may recommend a radical mastectomy. This way, the lymph nodes can be removed and examined. This tells your doctor whether cancer cells have spread beyond your breast.

Partial Mastectomy

In a partial mastectomy, the surgeon removes the cancerous part of the breast tissue. Some normal tissue around it is also removed. Technically, a lumpectomy can be considered a partial mastectomy. However, more tissue is removed in a true partial mastectomy.

When is a Partial Mastectomy Called For?

If you have stage 1 or 2 breast cancer, you may consider a partial mastectomy. In many cases, a partial mastectomy plus radiation therapy is as effective as a total mastectomy.

Subcutaneous ("Nipple-sparing") Mastectomy

If you have a subcutaneous ("nipple-sparing") mastectomy, the surgeon will remove all of your breast tissue, but leave your nipple alone. There are some possible disadvantages to this procedure:

• More breast tissue is left behind that could develop cancer
• Breast reconstruction after the mastectomy can cause distortion and numbness in your nipple

Because of these potential problems, many doctors still recommend a simple mastectomy instead.

Skin-sparing Mastectomy

A skin-sparing mastectomy leaves as much of your breast's skin as possible. During this procedure the surgeon removes the skin of your nipple, areola and the original biopsy scar. This creates an opening. Then the surgeon removes the breast tissue through this opening. What remains is a pouch of skin that offers the best shape to house an implant or reconstruction.

When is a Skin-sparing Mastectomy Called For?

Many women think this procedure gives them the most realistic reconstruction. Most women can have skin-sparing mastectomies. However, it may not be right for you if:

• You are not planning to have immediate breast reconstruction
• There's a chance that tumor cells are close to the skin

If this is the case, they need to be removed to prevent the spread of cancer.

Is Mastectomy Right for You?

It's important to discuss your treatment options with your doctor. Together you can make the right decision about treatment. Mastectomy may be the right choice if:

• The tumor is larger than 5 centimeters. Stage and other factors weigh in here also. Your doctor may advise a mastectomy for some tumors less than 5 centimeters. Others less than 5 centimeters may require only a lumpectomy.
• Your breast is small. This would mean that a lumpectomy would leave you with very little breast tissue.
• Your surgeon has tried multiple times to remove the tumor with a lumpectomy but has not been able to completely remove it and get clear margins.
• You have a small tumor (under 4 ) but lumpectomy plus radiation is not an option for you. Reasons why it would not be an option include that you've already had radiation to that breast; you are pregnant; or your have a disease like lupus or rheumatoid arthritis.
• You feel that a mastectomy would give you greater peace of mind than a lumpectomy.

If I have a mastectomy, will I need radiation? If so, what does that involve?

Mastectomy Plus Radiation

You may need radiation after your mastectomy if:

• Your tumor is larger than 5 centimeters
• The tissue removed during mastectomy does not have clear margins
• Your surgeon finds cancer cells in four or more lymph nodes
• The cancer was found in multiple locations within your breast

In these cases, radiation will typically follow chemotherapy.

Mastectomy: What to Expect

Before your mastectomy, your surgeon or a nurse will draw on your breast with a felt-tip marker. This will show you where the incision will be. You will be sitting up when this is done so that the natural crease of your breast can be followed.

You will be given anesthesia. A nurse will insert a needle connected to a long tube. This is called an intravenous infusion (IV) line. It will be either in your hand or your arm and will be taped into place. The nurse will give you medication to relax you through this IV line. Once you are in the operating room, you will be given general anesthesia.

How long does the surgery take and how long will I be in the hospital?

About the Mastectomy Surgery

On average, a mastectomy can take two to three hours. If you're having reconstruction at the same time, the surgery will take longer.

Usually the surgeon will make the incision in the shape of an oval around the nipple. It will run across the width of your breast. If you are having a skin-sparing mastectomy, the incision will be smaller.

In a mastectomy, the surgeon separates the breast tissue from the overlying skin. The breast tissue is also separated from the chest wall muscle underneath unless you are having a full radical mastectomy.

All of the breast tissue is removed. Some lymph nodes may be removed as well, if your surgeon suspects the cancer has spread to them. If you are having immediate breast reconstruction, then that will begin as soon as all breast tissue is removed.

The final step is for the surgeon to insert surgical drains. These are long tubes inserted in your breast area or armpit. This is necessary because extra fluid can build up in the space where the tumor was. These tubes help the fluid leave your body. After the drains are put in, your surgeon will stitch the incision closed. Then the surgeon will cover your chest will a tight bandage.

You'll stay in a recover room right after surgery. Nurses will monitor all your vital signs. You can be given medication if you are in any pain. Typically, you will stay in the hospital for up to three days. The stay may be a little longer if you have had reconstruction at the same time.

You will need someone to drive you home from the hospital. You may also want your caregiver to be present when you receive your instructions for post-surgery care.

Recovering from a Mastectomy

Bandage: Before you leave, your surgeon or nurse will instruct you in caring for the bandage or dressing. Sometimes, you will need to do nothing to the bandage until your follow-up visit.

Drain Bulbs: After a mastectomy, the drain in your armpit or breast area usually stays in until the first follow-up visit with the surgeon. This appointment is usually one-two weeks after surgery. You will need to empty the fluid from the detachable drain bulb several times a day. You will also need to record the amount of fluid collected in the bulb. For the first few days, the drainage will be red because of blood cells, but it will change color. It's important to drain this fluid away so it does not collect in the surgical incision. Your surgical team will teach you how to care for your drain before you leave the hospital.

Arm Exercises: It's important to begin exercising the morning after your surgery. Your doctor or nurse will show you simple exercises. This will keep your arm and shoulder from getting stiff. There are some exercises that will need to be avoided until drains are removed. Don't worry that you'll forget how to do the exercises once you're at home. You will be given written, illustrated instructions that remind you how.

Before you leave the hospital, you will receive information about recovering at home. The instructions should cover the following:

• Taking pain medicine
• Caring for your bandage
• Caring for the surgical drain
• Your stitches and staples
• Recognizing signs of infection
• Recognizing signs of lymphedema
• When you can start wearing a prosthesis or bra

If you have any questions, contact your healthcare team immediately.

Your Recovery at Home

Be prepared for it to take your body a few weeks to recover from a mastectomy. It can take longer if you had reconstruction. Make sure you give yourself adequate time to heal. Here are some ways to plan for your recovery at home:

• Don't make too many plans for the first few weeks after surgery. Realize that you're going to need extra rest.
• Get help from friends and family. You'll need help with meals, laundry, and childcare. Accept offers of help from family and friends graciously. Don't feel as if you're imposing. How would you feel if a relative or friend were in your shoes? Wouldn't you be very happy to help out?
• Take pain medication if you need it. Most people report some numbness and pain after a mastectomy. If you're in pain, take medication. Always follow your doctor's instructions regarding pain medication. Make sure to get any pain medications filled as soon as you leave the hospital. Perhaps a friend or relative can do this for you. That way, the pain medication is on hand if and when you need it.
• Make sure to do arm exercises every day. These will prevent stiffness.
• Expect “phantom” sensations or pain in the months to com This is normal. The reason for these sensations is that your nerves have to regrow. Taking analgesics and NSAIDs like acetaminophen (Tylenol) and ibuprofen can help relieve this discomfort.

Questions to Ask Your Surgeon About Mastectomy

If you are considering a mastectomy for your breast cancer treatment, here are some questions to ask your surgeon:

• How many mastectomies have you performed?
• What are the risks of mastectomy?
• How long will surgery take?
• How long will I stay in the hospital?
• Will I need to have any underarm lymph nodes removed?
• Will I need blood transfusions? Should I donate my own blood before surgery?
• Am I a good candidate for immediate breast reconstruction?
• What are the risks of having reconstruction surgery?
• If I have immediate breast reconstruction, how will my breast look after surgery?
• If I don't have immediate reconstruction, how will my chest look after surgery?
• Will I be at risk for lymphedema after surgery?
• Will you give me written instructions to follow as I recover?
• Are there exercises I need to do after surgery?
• When can I return to my normal routine and activities?
• What are signs of infection I should look for?
• Whom should I call if I have questions?
• What is the best way to get in touch with your office?
• When will I need to come in for a follow-up visit?

Some women choose to have their breasts reconstructed after surgery. There are two main types of breast reconstruction surgery:

• Implants
• Tissue flap procedures (tissues taken from another part of the body)

Implants and Expanders

Breast implants can often be done at the same time as a mastectomy. When implants take place at the same time as a mastectomy, it is called “immediate reconstruction.” This is a good option for some women. However, this is not a good option for women with high-risk tumors. It may also not be a good option for women with lower-risk tumors who are going to do radiation therapy after surgery. This is because radiation may alter the appearance or feeling of the reconstructed breasts. For this reason, many women choose to do reconstructive surgery at a later time in their cancer journey.

Implants are either silicone or saline. Alternative types of breast implants may be available through clinical trials. Reconstructive surgery involving implants is usually a two-step process.

1. The first step is to insert expanders under the skin and chest muscle. The expanders create space for the implants. Over the next six to 10 weeks, your surgeon will gradually inject more saline into the expanders to stretch the skin and tissue. While this process can be uncomfortable, you will still be able to go about most of your daily activities. Ask your surgeon about your need to limit your physical activities.
2. The second step is to remove the expanders and insert the saline or silicone implant

Recovery is generally three to four weeks.

Benefits of Breast Implants

Compared to other breast reconstruction options, implants have the following benefits:

• Less extensive surgery
• Shorter recovery time
• Fewer scars

Risks of Breast Implants

• Implants can rupture or leak. You may need regular breast MRIs to check for ruptures or leaks.
• Implants will likely need to be replaced at some point in your lifetime.
• Implants may feel less like natural breasts than breasts reconstructed from your own tissues.
• With any surgery, there is a risk of infection.

Tissue Flap Procedures

Tissue flap procedures use tissues from your own body to reconstruct breasts. Tissues may be taken from the abdomen, back, thighs, or buttocks. The two most common flaps used are the TRAM (transverse rectus abdominis) flap and the latissimus dorsi flap (see below for more information). Recovery time can be four to six weeks or longer for some procedures.

Explained below are the different options for tissue flap procedures:

• TRAM (transverse rectus abdominis) flap - Uses skin, fat, and muscle from the lower abdomen to reconstruct breasts
• Latissimus dorsi flap - Uses skin, fat, and muscle from the upper back to reconstruct breasts
• DIEP (deep inferior epigastric artery perforator) flap - Uses skin and fat only from the lower abdomen to reconstruct breasts.
• TAP or TDAP (thoracodorsal artery perforator) flap - Uses skin and fat only from the upper back to reconstruct breasts.
• GAP (gluteal artery perforator flap)- Uses fat and skin from the buttocks to reconstruct breasts. Can be taken from superior/upper buttocks (S-Gap) or inferior/lower buttocks (I-Gap).
• TUG (transverse upper gracilis) flap - Uses muscle and fat from inner thigh to reconstruct breasts.

The options for tissue flap procedures vary by location and surgeon. Your surgeon can discuss all your options with you.

Benefits of Tissue Flap Procedures

• Breasts reconstructed with your own tissue are more likely to feel and look like natural breasts.
• With tissue flap procedures there is no risk of ruptures or leakage, and after healing, tissue flaps will never have to be replaced.

Risks of Tissue Flap Procedures

• Longer recovery time
• Scars where the tissue flap is removed
• Flap necrosis (The tissues flap could die. This is rare.)
• With any surgery, there is a risk of infection.

Nipple and Areola Reconstruction

Nipple and areola reconstruction is another optional part of breast reconstruction. Usually, it is a separate surgery that occurs four to five weeks after the reconstructed breasts have healed. Nipples can be constructed from your own tissue from breasts, thighs, buttocks, or other areas. Nipples can also be tattooed onto the skin. Both of these are outpatient procedures.

For women with early stage breast cancer, a nipple-sparing mastectomy may be possible. In this procedure, only the breast tissue under the nipple is removed.

Questions To Ask Your Surgeon About Breast Reconstruction

Discuss all your options with your surgeon to choose which type of breast reconstruction (if any) is right for you. Use these questions to begin the conversation:

• Which type of reconstruction would you recommend? Why?
• What are my other options?
• What are the risk and benefits of each of my options?
• If I choose to do an implant, what type of implant would you recommend?
• What are my options for nipple and areola reconstruction?
• What is the recovery time? When will I be able to return to my normal activities?
• What can I expect my breasts to look like after surgery? Do you have pictures of any past patients?
• Will I have feeling in my breasts?
• Will my health insurance cover the costs?

Chemotherapy treatment (usually called “chemo”) involves using medicines that prevent cancer cells from growing and spreading. Chemotherapy medicines do this by destroying cancer cells altogether or preventing them from dividing. Chemo affects your whole body because it goes through your bloodstream.

When is chemotherapy used?

• In early-stage invasive breast cancer to get rid of any cancer cells that may be left behind after surgery. Chemo helps decrease the risk of the cancer coming back.
• In advanced-stage breast cancer to destroy or damage the cancer cells as much as possible.
• In some cases, chemo is used before breast cancer surgery in order to shrink the cancer. This is called neoadjuvant chemotherapy. It is used when a tumor is inoperable at its current size or to make breast sparing surgery a possibility.
• It is relatively common for chemo treatment to begin after surgery and recovery.

Chemotherapy not only weakens and destroys cancer cells at the site of the tumor, but throughout the body as well. Unfortunately, this means that chemo can unintentionally harm the development of normal cells like your hair, nails, mouth, and digestive tract.

Chemo doesn't refer to one treatment but many, because there are lots of different chemotherapy medicines. Brand names for common chemotherapy medications for breast cancer include:

• Carboplatin (Paraplatin)
• Capecitabine (Xeloda)
• Cyclophosphamide (Cytoxan)
• Daunorubicin (Cerubidine, DaunoXome)
• Docetaxel (Taxotere)
• Doxorubicin (Adriamycin, Doxil)
• Epirubicin (Ellence)
• Eribulin (Halaven)
• Fluorouracil (Adrucil)
• Gemcitabine (Gemzar)
• Ixabepilone (Ixempra)
• Methotrexate (Folex, Mexate)
• Mitomycin
• Mitoxantrone (Novantrone)
• Paclitaxel (Abraxane, Taxol)
• Thiotepa (Thioplex)
• Vincristine (Oncovin, Vincasar PES, Vincrex)
• Vinorelbine (Navelbine)

Sometimes, your doctor may combine two or more medicines to treat your breast cancer. These combinations are called chemotherapy regimens. Common regimens include:

• AT: Adriamycin and Taxotere
• AC + T: Adriamycin and Cytoxan, with or without Taxol or Taxotere
• CMF: Cytoxan, methotrexate, and fluorouracil
• CEF: Cytoxan, Ellence, and fluorouracil
• FAC: Fluorouracil, Adriamycin, and Cytoxan
• CAF: Cytoxan, Adriamycin, and fluorouracil (Note: the difference in the CAF and FAC regimens is not in the medicines but in the doses and frequencies)
• TAC: Taxotere, Adriamycin, and Cytoxan
• GET: Gemzar, Ellence, and Taxol

Your doctor may refer to specific groups of chemotherapy medicines:

• Anthracyclines: In terms of their chemistry, these are similar to an antibiotic. They make the cancer cells die by damaging their genetic material.
• Taxanes affect the way cancer cells divide.

What to Expect with Chemotherapy

Chemo medicines come in different forms and can be given in different ways:

• Intravenously (IV): As an infusion, the medicine comes through a thin needle (IV) in a vein in your hand or lower arm. An oncology nurse will insert the needle before each infusion and take it out afterwards.
• Injection: As a single shot into a muscle in your leg, arm, hip, or under the skin in the fatty part of your stomach, leg or arm.
• By mouth: As a pill or capsule. You may take this yourself at home.
• Through a port: This is inserted in your chest during a short outpatient surgery. It is about the size of a quarter and sits right under your skin. A port is a small disc made of plastic or metal. A catheter (soft thin tube) connects the port to a large vein. The chemo medicines are delivered through a thin needle right into the port. You can also get your blood drawn through the port. Once you have finished chemo, the port is removed in a brief outpatient procedure.
• Through a catheter in your chest: This is a soft thin tube that is inserted into a large vein. This is done in a short outpatient surgery. The other end of the catheter stays outside your body. This is similar to having a port.

If you have a catheter or port, you will need to watch for infection. Your healthcare team will tell you signs of infection.

What's the Advantage to a Port or Catheter?

Many doctors recommend getting a catheter or port because it makes chemotherapy easier and more comfortable each time, as you won't have to be restuck each time, as you do with an IV or injection. Also, a port may be a good idea if you are having problems with arm lymphedema.

Some breast cancer patients have a portable pump attached to the port or catheter. This controls how much and how fast the chemotherapy medicine goes in. The pump can either be internal (implanted under the skin during a short outpatient procedure) or external (carried with you). Once your rounds of chemo are done, the pump is taken out.

Setting Your Schedule

Your oncologist will set your treatment regimen. Every chemo regimen is made up of cycles. This means a period of treatment followed by a period of recovery. For example, you may get chemo one day and then have a few weeks of recovery with no treatment. That would be one cycle. Or you may get chemo for several days in a row and then have a recovery period. Several cycles make up a complete chemotherapy regimen. The number of cycles in a regimen and the length of each regimen varies from patient to patient. A lot depends on the medicines used.

For some patients, the doctor recommends a “dose-dense” chemo schedule. This means the chemo medicines are given every two weeks. Research has shown that dose-dense chemo can improve results and reduce the risk of breast cancer recurrence.

A disadvantage to dose-dense chemotherapy is that is doesn't allow much time for your immune system and red blood cells to recover between cycles. Doctors sometimes prescribe medicines that strengthen your immune system if you're going to have dose-dense chemo.

You can get chemotherapy in a variety of settings: at a hospital, in a doctor's office, in a clinic, or at home if you are taking chemo in a pill form or you have a portable pump. If you take chemo in a clinic, hospital or doctor's office, you usually go home between treatments. In some cases, you may stay in the hospital to be monitored. This is especially true if your immune system isn't working as well as it should be. Your doctor will explain where you'll be getting your treatment.

Passing Time During Chemotherapy

A chemotherapy treatment at a hospital or clinic can take anywhere from one to several hours. Although many chemo treatment areas have televisions and magazines, you may want to bring something to help pass the time. Ideas include:

• A laptop
• Knitting, needlepoint or crochet
• A thick novel
• Crossword or other puzzle book
• Sketchbook and pencils
• Cards or board games (if you have someone to play with)
• MP3 Player or portable CD player to listen to music
• Paper and pens to keep a journal or write letters

Planning Ahead for Chemotherapy

Chemotherapy treatment can drain most of your energy. This is a major process your body is going through. There are some things you should take care of before you start chemo:

• Get your teeth cleaned and get a dental check. Chemo weakens your immune system, so you may be more vulnerable to infections caused by bacteria that are dislodged during teeth cleaning.
• Get any heart tests (like an EKG) that your doctor recommends.
• Get a Pap smear, if you're overdue. Chemo can alter the results of your Pap smear, so get one beforehand.
• Find someone to help around the house. Chemo causes extreme fatigue. Line up someone to help with your daily chores: cleaning, grocery shopping, carpooling, and cooking, to name a few. Don't be afraid or embarrassed to ask for help. Friends and family members will be happy to do something that helps you during this treatment phase. Ask yourself: wouldn't you be willing to do it for someone else?
• Join a support group, if that sounds helpful.
• Find out ahead of time what you should and shouldn't eat or drink on treatment days.
• Tell your doctor all the vitamins, supplements, over-the-counter and prescription medicines you take.
• Talk to your doctor about hair loss. Most chemo medicines cause some amount of hair loss. If you plan on wearing a wig, you might want to go ahead and get it so you can match it to your hair color and style.

Radiation therapy is also called radiotherapy or simply radiation. This is a very effective way to destroy cancer cells that may remain after the breast surgery. Radiation can pinpoint the cancer cells very well. Estimates are that radiation can reduce the risk of breast cancer coming back by about 70%.

In addition, radiation therapy is relatively easy to tolerate, because its side effects are mostly limited to the treated area. Fatigue is the most common full-body side effect.

A radiation oncologist will oversee your radiation treatments. There are 3 major types of radiation:

External Radiation: The most common type of radiation is external radiation. It is usually given after lumpectomy. It may also be given after a mastectomy.

Internal Radiation: A less common method is internal radiation. It is primarily used after a lumpectomy.

MammoSite Radiation Therapy System (RTS) is a type of high dose internal radiation therapy used specifically after a lumpectomy. A member of the healthcare team will insert a balloon catheter into the breast at the site of the lumpectomy. The catheter will then be expanded, and a tiny bead is inserted into the area. This bead will deliver the radiation therapy. Since this type of radiation targets one small area, it protects surrounding healthy tissue from the damage caused by radiation.

Intraoperative Radiation: A relatively new type of radiation is intraoperative radiation therapy (IORT). This is given during lumpectomy surgery once the cancer has been taken out.

Is Radiation Necessary for Me?

Radiation therapy is appropriate for all stages of breast cancer because it is relatively safe and very effective. Radiation can also be given to people with stage IV cancer that has spread to other parts of the body.

Radiation is never safe for pregnant women.

Lumpectomy with Radiation

Radiation is designed to destroy any cancer cells that are left in the breast after the tumor has been removed.

Usually a doctor will recommend that you have radiation after your lumpectomy if the cancer is:

• Early stage
• Four centimeters or smaller in size
• Located in one site
• Removed with clear margins

Mastectomy with Radiation

During a mastectomy, it's hard to remove every cell of breast tissue. It's especially hard to remove the tissue behind the skin in front of your breast or along the muscle behind your breast. It's possible for some breast cancer cells to remain in these places. This is why there could be a risk for recurrence in the area where your breast was.

Your doctor may recommend radiation if you have any of the following risk factors after your mastectomy:

• Cancer has invaded the lymph channels and blood vessels in your breast
• The cancerous tissue that was removed has a positive margin
• At least four lymph nodes were involved
• You are premenopausal, and at least one lymph node was involved
• Cancer has invaded your skin
• The tumor is five centimeters or larger

It is estimated that 20 to 30% of people with these risk factors are a higher risk of recurrence. This is why radiation can be an important treatment, because it reduces the risk of recurrence.

Radiation is not appropriate for you if:

• You are pregnant
• You have already had radiation to that part of your body
• You have a connective tissue disease, like vasculitis
• You cannot commit to the daily regimen of radiation therapy

When is Radiation Given?

For some people, radiation is given right after surgery. Sometimes, however, it is given after another treatment, like chemotherapy or hormonal therapy. Every patient's cancer is different. Your doctor will discuss the specific treatment routine you'll need. As a rule of thumb, if you need chemotherapy, that will come before radiation.

Radiation Therapy: What to Expect

Most side effects of radiation involve the skin of the area being treated. When you're first undergoing radiation, you'll notice your skin color change from pink to red. It will look like sunburn. You will probably also have itching, burning, soreness or peeling.

Some areas of your skin may react more than others. Problem areas often include:

• Skin along the fold under your breast
• Skin of your armpit
• Skin in the upper corner of your breast

Some skin has a more dramatic reaction to radiation. This is likely if:

• You have large breasts
• Your complexion is fair and you get sunburns more easily
• You have recently had chemotherapy
• You are receiving radiation after mastectomy, and the treatment delivers a high dose to the skin

Just like with a sunburn, your skin may be dry, sore, and more sensitive to touch. You skin may start to peel. If this happens, it tends to be toward the end of your treatments or later. Watch for signs of infection. Your oncologist will tell you what to look for.

The good news is that skin irritation caused by radiation is temporary. Your doctor can also give you salves, medications and prescriptions to ease the discomfort.

After the Treatment

Once you finish radiation, your skin may continue to get worse for another week or so. Then it will start to get better. There are things you can do to prevent irritation before and after treatments:

• Wear loose-fitting cotton shirts
• Avoid letting shower water fall directly on your breast
• Shower in warm instead of hot water
• Avoid harsh soaps; use fragrance-free soaps with moisturizers
• Wear a good support bra with no underwire to keep your breasts separated and lifted

If your skin becomes very irritated, you can take several steps to minimize the irritation:

• Moisturize your skin with an ointment like Eucerin, A&D, or Radiacare
• Apply an aloe vera ointment or 1% hydrocortisone cream. Use the cream three times a day.
• Blow on the area with a hair dryer sets to cool or air (no heat).
• If your skin forms a blister, leave it alone. It is designed to keep the area clean while the new skin grows back.

Regarding sun exposure:

• Keep the treated area out of the sun.
• Wear a cover-up when you're not in the water—like an over-sized cotton shirt.
• Avoid chlorine because it's very drying.
• Use a sunscreen that is at least SPF 30 on the area that was treated.
• Re-apply sunscreen every few hours.

To understand hormonal therapy you must first know that many breast cancers are hormone receptor-positive. This means that the estrogen hormone makes the cancer cells in your breast grow. Hormonal therapy treats hormone receptor-positive breast cancers. This kind of therapy only affects the action of estrogen in breast cancer cells, not progesterone. It is not used, then, if your breast cancer is progesterone receptor-positive.

Hormonal therapy medicines treat hormone receptor-positive breast cancers by:

• Blocking the activity of estrogen in your body
• Lowering the amount of estrogen in your body

Your ovaries are the main source of estrogen before menopause. Therefore, if you are pre-menopausal and diagnosed with estrogen receptor-positive breast cancer, you may choose to shut down your ovaries through medicine or surgery.

Two option treatment options include:

• Tamoxifen: Tamoxifen prevents the action of estrogen in breast tissue by preventing estrogen molecules from reaching the hormone receptors.
• Aromatase inhibitors: Aromatase inhibitors help lower the amount of estrogen in your body.

Hormonal therapy is also used to decrease the risk of early-stage, hormone receptor positive breast cancer coming back after surgery. It is also used to treat advanced/metastatic hormone receptor positive breast cancer. Pre-menopausal women can use hormonal therapy. Hormonal therapy can be given before, at the same time as, or after other breast cancer treatments. Hormonal therapy is never safe during pregnancy.

Which Hormonal Therapy is Right for Me?

You and your doctor will consider several factors when identifying the best hormonal therapy medicine for you:

• Your breast cancer stage
• Your stage of menopause
• Whether you've had any blood clots
• Your bone density
• Whether you've had any arthritis

If you have side effects from one therapy, you may be able to switch to another.

How Do I Take Hormonal Therapy?

All the hormonal therapy medicines except one, Faslodex (fulvestrant) are pills. They are taken once a day. The medicines can be taken with or without food. Faslodex is a liquid that is injected into your muscle once a month. Most hormonal therapies are taken long term, five years or longer. Some women begin taking tamoxifen then switch to an aromatase inhibitor after the first two to three years.

Questions to Ask Your Doctor about Hormonal Therapy

I have just been diagnosed with hormone receptor positive breast cancer. What questions should I ask?

• What are the benefits and risks of aromatase inhibitors for me?
• For me, what are the benefits and risks of tamoxifen?
• Does an aromatase inhibitor or tamoxifen make more sense for me?
• How long will I need to take hormonal therapy?
• Do I need a bone density test?

I have taken tamoxifen for two to three years. What questions should I ask?

• Would there be any benefits to switching to an aromatase inhibitor?
• If I don't switch to an aromatase inhibitor, how much longer will I take tamoxifen?
• How long would I take anaromatase inhibitor if I did switch?
• Will I have different side effects if I switch to an aromatase inhibitor?

I have finished five years of tamoxifen or an aromatase inhibitor. What questions should I ask?

• Should I now take a different type of hormonal therapy for an additional five years? If so, what are the benefits?
• Should I keep taking my current hormonal therapy medicine for longer than five years? If so, what are the benefits?
• How many years would I take an aromatase inhibitor? How many years would I take tamoxifen?
• What side effects are possible with an aromatase inhibitor? With tamoxifen?

Biological therapy is a treatment that works with your immune system. This therapy takes advantage of the body's own immune system to act on cancer cells while leaving healthy cells relatively intact. All the parts of your immune system help protect you from getting diseases and infection. Your immune system includes the:

• Spleen
• Lymph nodes
• Tonsils
• Bone marrow
• White blood cells

White blood cells are particularly important to your immune system. Here are some terms you might hear:

• Neutrophils, monocytes, and lymphocytes are types of white blood cells.
• B cells, T cells, and natural killer cells are types of lymphocytes.

Your immune system is able to tell the difference between good cells that keep you healthy and bad cells that make you sick.

Biological therapy can serve two purposes. First, it can help fight cancer by:

• Stopping or slowing the growth of cancer cells
• Making it easier for your immune system to destroy cancer cells
• Keeping cancer from spreading to other parts of your body

One form of biological therapy is cancer vaccines. There have been many vaccines studied in breast cancer to stimulate the immune system to destroy cancers. Many non-cancer vaccines are given before you get sick, but most cancer vaccines are given once you have a diagnosis of cancer. These vaccines help your body fight the cancer and keep it from returning.

Another strategy to attack breast cancer cells is to use antibodies. Antibodies are proteins that can attach or stick to other specific proteins in the body or on the cancer. Antibodies can be natural or made by the body's own immune system or made artificially.

There are two approved antibodies for breast cancer:

• Herceptin (trastuzumab)
• Perjeta (pertuzumab)

These antibodies only work if the tumor expresses the human epidermal growth factor receptor 2 (HER2) protein on its surface. Breast tumors that have this protein are said to be HER2+. The treatment antibodies work by sticking to the cancer and cause them to stop growing. They can also stick to the cancer cell and flag or signal the body's own immune system to attack the cancer cells. Most of these are given by injection.

There are many types of other biological therapies. One uses drugs that interrupt the pathways in the cell that tell cancer cells to grow. Some are combined with chemotherapy and some with hormonal therapies. Some of these block signals inside the cancer cell that tells the cancer cells when to divide. Afinitor (everolimus) has recently been approved for advanced hormone receptor positive breast cancer. Most of these drugs are taken by mouth.

Another type of therapy uses antibodies to inhibit the growth of new blood vessels and cuts off the nutrients to the cancer cell. Many trials in different cancers have reported improvements in disease control and survival with these agents. For breast cancer, many trials are underway evaluating their benefit.