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Breast cancer
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Breast cancer

WOMEN'S HEALTH

Cancer

From MayoClinic.com

Diagnostic procedures

If you, your doctor or a mammogram detects a lump in your breast, you'll likely have one or more diagnostic procedures to determine if the lump is cancerous, including:

Ultrasound

Often, your doctor will suggest a less invasive procedure, such as ultrasound, before deciding on a biopsy. Ultrasound is a procedure that uses sound waves to create an image of your breast on a computer screen. By analyzing this image, your doctor may be able to tell whether a lump is a cyst or a solid mass. Cysts, which are sacs of fluid, usually aren't cancerous, although you may want to have a painful cyst drained with a needle.

Biopsy

In some cases, your doctor may want to remove a small sample of tissue (biopsy) for analysis in the laboratory. To do so, he or she may use one of the following procedures:

Fine-needle aspiration biopsy. The simplest type of biopsy, this is used for lumps you or your doctor can feel. During the procedure your doctor uses a thin, hollow needle to withdraw cells from the lump. He or she then sends the cells to a lab for analysis. The procedure isn't uncomfortable, takes about 30 minutes and is similar to drawing blood. Another procedure, fine-needle aspiration, is used primarily to remove the fluid from a painful cyst, but it can also help distinguish a cyst from a solid mass.

Core needle biopsy. During this procedure, a radiologist or surgeon uses a hollow needle to remove tissue samples from a breast lump. As many as 15 samples, each about the size of a grain of rice, may be taken, and a pathologist then analyzes them for malignant cells. The advantage of a core needle biopsy is that it removes tissue, rather than just cells, for analysis. Sometimes your radiologist or surgeon may use ultrasound to help guide the placement of the needle.

Stereotactic biopsy. This technique is used to evaluate an area of concern that can be seen on a mammogram but that cannot be felt or seen on an ultrasound. During the procedure, a radiologist takes a core needle biopsy, using your mammogram as a guide. Stereotactic biopsy usually takes about an hour and is performed using local anesthesia.

Wire localization. Your doctor may recommend this technique when a worrisome lump is seen on a mammogram but can't be felt or evaluated with a stereotactic biopsy. Using your mammogram as a guide, a thin wire is placed in your breast and the tip guided to the lump. Wire localization is usually performed right before a surgical biopsy, and is a way to guide the surgeon to the area to be removed and tested.

Surgical biopsy. This remains one of the most accurate methods for determining whether a breast change is cancerous. During this procedure, your surgeon removes all or part of a breast lump. In general, a small lump will be completely removed (excisional biopsy). If the lump is larger, only a sample will be taken (incisional biopsy). The biopsy is generally performed on an outpatient basis in a clinic or hospital.

Estrogen and progesterone receptor tests

If a biopsy reveals malignant cells, your doctor will recommend additional tests - such as estrogen and progesterone receptors tests - on the malignant cells. These tests help determine whether female hormones affect the way the cancer grows. If the cancer cells have receptors for estrogen or progesterone or both, your doctor may recommend treatment with a drug such as tamoxifen that prevents estrogen from binding to these sites.

Staging tests

Staging tests help determine the size and location of your cancer, and whether it has spread. They also help your doctor determine the best treatment for you. Cancer is staged using the numbers 0 through IV.

Stage 0 cancers are also called noninvasive or in situ (in one place) cancers. Although they don't have the ability to spread to other parts of your body or invade normal breast tissue, it's important to have them removed because they eventually can become invasive cancers. Finding and treating a cancerous lump at this stage offers the best chance for a full recovery.

Stage I to IV cancers are invasive tumors that have the ability to spread to other areas. A stage I cancer is small and well localized, and has a very successful treatment rate. But the higher the stage number, the lower the chances of cure. By stage IV, the cancer has spread beyond your breast to other organs, such as your bones, lungs or liver. Although it may not be possible to eliminate the cancer at this stage, its spread may be controlled with radiation, chemotherapy or both.

Genetic testing

The discovery of BRCA1, BRCA2 and other genes that may significantly increase breast cancer risk has raised a number of emotional and legal questions about genetic testing. A simple blood test can help identify defective BRCA genes, but it's only 85 percent accurate, and most experts believe that only those women at high risk of hereditary breast or ovarian cancers should be referred for testing. If you're one of these women, it's important to know that having a defective BRCA gene doesn't mean you'll get breast cancer. In addition, test results cannot determine how high your risk is, at what age you might develop cancer, how aggressively the cancer might progress or what your risk of death may be.

In general, testing is most beneficial if the results of the test will help you make a decision about how you might best reduce your chance of developing breast cancer. Options range from lifestyle changes, closer screening and therapy with medications such as tamoxifen to extreme measures such as preventive (prophylactic) bilateral mastectomy or removal of your ovaries (oophorectomy). These can be wrenching decisions for any woman to make. Be sure to thoroughly discuss all your options with a genetic counselor, who can explain the risks, benefits and limitations of genetic testing. It can also help to talk to other women who have had to make similar decisions.

Treatment

A diagnosis of breast cancer is one of the most difficult experiences you can face. In addition to coping with a life-threatening illness, you must make complex decisions about treatment. Remember, in most cases no one right treatment exists for breast cancer. Instead, you'll want to find the approach that's best for you.

To do that, you'll need to consider many different factors, including the type and stage of your cancer, your age, risk factors, where you are in your life, the size and shape of your breasts, and your feelings about your body.

Before making any decisions, learn as much as you can about the many treatment options that exist. Talk extensively with your health care team. Consider a second opinion from a breast specialist in a breast center or clinic. Don't be afraid to ask questions. In addition, look for breast cancer books, Web sites and information available from organizations such as the American Cancer Society and the Susan G. Komen Breast Cancer Foundation. Talking to other women who have faced the same decision also may help. This may be the most important decision you ever make.

Treatments exist for every type and stage of breast cancer. Most women will have surgery and an additional (adjuvant) therapy such as radiation, chemotherapy or hormone therapy. And several experimental treatments are now offered on a limited basis or are being studied in clinical trials.

Surgery

At one time, the only type of breast cancer surgery was radical mastectomy, which removed the entire breast, along with chest muscles beneath the breast and all the lymph nodes under the arm. Today, this operation is rarely performed. Instead, the majority of women are candidates for breast-saving operations, such as lumpectomy. Less radical mastectomies and mastectomy with reconstruction are also options.

Breast cancer operations include the following:

  • Lumpectomy. This operation saves as much of your breast as possible by removing only the lump plus a surrounding area of normal tissue. Your surgeon will likely also do a sentinel lymph node dissection to check for possible spread of cancer. In most cases, your operation will be followed by radiation therapy to kill any remaining cancer cells. You usually have radiation therapy every weekday for six to seven weeks. Many women can have lumpectomy plus radiation instead of mastectomy, and in most cases survival rates for both operations are the same. In addition, many more women are satisfied with their appearance after lumpectomy. But lumpectomy may not be an option if a tumor is deep within your breast, or if you've already had radiation therapy, have two or more areas of cancer in the same breast that are far apart, have a connective tissue disease that makes you sensitive to radiation or are pregnant. Keep in mind that if you choose lumpectomy, you'll often also need radiation.
  • Partial or segmental mastectomy. Also considered a breast-sparing operation, partial mastectomy involves removing the tumor as well as some of the breast tissue around the tumor and the lining of the chest muscles that lie beneath it. Some lymph nodes under your arm also may be removed. In almost all cases, you'll have a course of radiation therapy following your operation.
  • Simple mastectomy. During a simple mastectomy, your surgeon removes all your breast tissue - the lobules, ducts, fatty tissue and a strip of skin with the nipple and areola. Depending on the results of the operation and follow-up tests, you may also need further treatment with radiation, chemotherapy or hormone therapy.
  • Modified radical mastectomy. In this procedure, a surgeon removes your entire breast and some underarm (axillary) lymph nodes, but leaves your chest muscles intact. This makes breast reconstruction less complicated. But serious arm swelling (lymphedema) - a common complication of mastectomy - is more likely to occur in modified radical mastectomy than in simple mastectomy with sentinel node biopsy. Your lymph nodes will be tested to see if the cancer has spread. Depending on those results, you may need further treatment.
  • Sentinel lymph node biopsy. Breast cancer first spreads to the lymph nodes under the arm. That's why all women with invasive cancer need to have these nodes examined. If your surgeon doesn't plan to do this, be sure you understand the reason why. Until recently, surgeons would remove as many lymph nodes as possible. But this greatly increased the risk of numbness, recurrent infections and lymphedema - a serious swelling of the arm. That's why a procedure has been developed that focuses on finding the sentinel nodes - the first nodes to receive the drainage from breast tumors and therefore the first to develop cancer. If a sentinel node is removed, examined and found to be healthy, the chance of finding cancer in any of the remaining nodes is very small and no other nodes need to be removed. This spares many women the need for a more extensive operation and greatly decreases the risk of complications.
  • Reconstructive surgery
    Most women who undergo mastectomy are able to choose whether to have breast reconstruction. This is a very personal decision, and there's no right or wrong choice. You may find, however, that you have feelings you didn't expect about your breasts. It's important to understand these feelings before making any decision.

    If you would like reconstruction but aren't a candidate for the procedure, you'll need to find a way to come to terms with your disappointment. It may be extremely helpful to talk to other women who have experienced the same situation.

    If reconstruction is an option, your surgeon will refer you to a plastic surgeon. He or she can describe the procedures to you and show you photos of women who have had different types of reconstruction. Your options include reconstruction with a synthetic breast implant or reconstruction using your own tissue to rebuild your breast. These operations can be performed at the time of your mastectomy or at a later date.

  • Reconstruction with implants. Using artificial materials to reconstruct your breast involves implanting a silicone shell filled either with silicone gel or salt water (saline). If you don't have enough muscle and skin to cover an implant, your doctor may use a tissue expander. This is an empty implant shell that inflates as fluid is injected. It's placed under your skin and muscle, and your doctor gradually fills it with fluid - usually over a period of several months. When your muscle and skin have stretched enough, the expander is removed and replaced with a permanent implant. Recovery may take several weeks. In general, an implant makes your breast firmer than a normal breast. Implants may cause pain, swelling, bruising, tenderness or infection. And they do age over time, requiring replacement. There is also a long-term possibility of rupture, deflation and shifting.
  • Reconstruction with a tissue flap. Known as a transverse rectus abdominis myocutaneous (TRAM) flap, this surgery reconstructs your breast using tissue, including fat and muscle, from your abdomen. Sometimes your surgeon may also use tissue from your back or buttocks. Because the procedure is fairly complicated, recovery may take six to eight weeks. You may also need future adjustments to the breast. Complications include the risk of infection and tissue death. If you have little body fat, this type of reconstruction may not be an option for you. On the other hand, a breast reconstructed from your own tissue doesn't seem to interfere with the detection of tumors. It's also permanent, and has the look and feel of a normal breast.
  • Deep interior epigastric perforator (DIEP) reconstruction. In this procedure, fat tissue from your abdomen is used to create a natural-looking breast. But because your abdominal muscles are left intact, you're less likely to experience complications than you are with traditional breast reconstruction. You may also have less pain, and your healing time may be reduced.
  • Reconstruction of your nipple and areola. After initial surgery with either tissue transfer or an implant, you may have further surgery to make a nipple and areola. Using tissue from elsewhere in your body, your surgeon first creates a small mound to resemble a nipple. He or she may then tattoo the skin around the nipple to create an areola. Your surgeon may also take a skin graft from elsewhere on your body, place it around the reconstructed nipple to slightly raise the skin and then tattoo the skin graft.

Radiation therapy

Radiation therapy uses high-energy X-rays to kill cancer cells and shrink tumors. If you choose lumpectomy, or if a biopsy has confirmed that there are cancer cells in more than four lymph nodes in your armpit, your oncologist will likely recommend radiation to your chest wall after your mastectomy. Although the thought of radiation can be disturbing, it may help to know that it's a more accurate and less aggressive treatment than it once was.

Radiation is usually started three to four weeks after surgery. You'll typically receive treatment five days a week for six to seven weeks. The treatments are painless and are similar to getting an X-ray. Each takes about 30 minutes. The effects are cumulative, however, and you may become tired toward the end of the series. Your breast may be pink, puffy and somewhat tender, as if it had been sunburned.

More serious, long-term complications are rare but can sometimes occur. These include rib fractures, lung inflammation, injury to the heart, nerve damage and a change in the appearance and consistency of breast tissue. In extremely rare cases, a new tumor may result from radiation therapy.

Chemotherapy

Chemotherapy uses drugs to destroy cancer cells. Your doctor may recommend chemotherapy following surgery to kill any cancer cells that may have spread outside your breast. Treatment often involves receiving two or more drugs in different combinations. These may be administered intravenously, in pill form or both. You may have between four and eight treatments spread over three to six months.

In some cases, your doctor may suggest preoperative chemotherapy - taking chemotherapy drugs to shrink a breast tumor before surgery. This may make it possible for you to have a lumpectomy rather than a mastectomy to remove the cancer, with the same survival rate as if you were to have chemotherapy after breast surgery.

No matter when it's administered, chemotherapy can feel like another illness. The side effects may include hair loss, nausea, vomiting and fatigue. These occur because chemotherapy affects healthy cells - especially fast-growing cells in your digestive tract, hair and bone marrow - as well as cancerous ones. Not everyone has side effects, however, and there are now better ways to control them if you do.

Many new drugs can help prevent or greatly reduce nausea. Relaxation techniques, including guided imagery, meditation and deep breathing also may help. In addition, exercise has been shown to be effective in reducing fatigue caused by chemotherapy.

Hormone therapy

Hormone therapy is most often used to treat women with advanced (metastatic) breast cancer or as an adjuvant treatment - a therapy that seeks to prevent a recurrence of cancer - for women diagnosed with early-stage estrogen-receptor-positive cancer. Estrogen-receptor-positive cancer means that estrogen or progesterone might encourage the growth of breast cancer cells in your body. Normally, estrogen and progesterone bind to certain sites in your breast and in other parts of your body. But during this treatment, a hormonal medication binds to these sites instead and prevents estrogen from reaching them. This may help destroy cancer cells that have spread or reduce the chances that your cancer will recur.

Medications that reduce the effect of estrogen in your body include:

  • Tamoxifen (Nolvadex). This is a synthetic hormone belonging to a class of drugs known as selective estrogen receptor modulators (SERMs). It's used as a treatment for metastatic breast cancer, as an adjuvant therapy, especially in women with breast cancer who have gone through menopause, and sometimes as a preventive agent in high-risk women. You take tamoxifen daily, in pill form, for up to five years. It may reduce the risk of recurrence of breast cancer and is less toxic than most anticancer drugs. But tamoxifen isn't trouble free. Women taking tamoxifen may experience menopausal symptoms such as night sweats, hot flashes, vaginal itch or discharge, and diminished sexual interest. Less common but potentially life-threatening side effects also can occur. These include blood clots in your lungs (pulmonary embolism) and legs (deep vein thrombosis) and endometrial cancer. Older women and women who are black are at greater risk of these side effects than are younger women or those who are white. In addition, some studies have shown that side effects of systemic adjuvant therapies - chemotherapy and tamoxifen - may be more long-term than originally thought.

Aromatase inhibitors.

This class of drugs inhibits the effect of estrogen by reducing its production in your adrenal glands. Aromatase inhibitors are currently approved only for the treatment of metastatic cancer, but early studies suggest that they may be more effective than is tamoxifen in preventing the recurrence of breast cancer. And one drug, anastrozole (Arimidex), may perform better than does tamoxifen as an adjuvant therapy. For now, though, many oncology experts believe tamoxifen should remain the adjuvant treatment of choice for women with hormone-receptor-

Biological therapy

Sometimes called biological response modifier or immunotherapy, this treatment tries to stimulate your body's immune system to fight cancer. Using substances produced by the body or similar substances made in a laboratory, biological therapy seeks to enhance your body's natural defenses against specific diseases. Many of these therapies are experimental and available only in clinical trials. One medication, trastuzumab (Herceptin), is a monoclonal antibody - a substance produced in a laboratory by mixing cells - that's available for treating certain advanced cases of breast cancer. Herceptin is effective against tumors that produce excess amounts of a protein called HER-2, which occurs in about 25 percent of breast cancers.

Clinical trials

A number of new approaches to treating cancer are being studied. The emphasis is on methods that can successfully treat women or extend their survival with minimal side effects. Among these are drugs that block the biochemical switches that cause normal cells to turn cancerous. In addition, a procedure known as anti-angiogenesis - which targets the blood vessels that supply nutrients to cancer cells - is also being studied. And gene therapy is an area of ongoing research.

Of particular interest to both women and their doctors are methods of removing breast cancer without actually cutting into or removing the breast. Nonsurgical methods being studied include techniques that use heat or cold to kill cancer cells deep within the breast, leaving only minimal scars.

One of the most researched techniques, radiofrequency ablation, uses ultrasound to locate the tumor. Then a metal probe about the size of a toothpick is inserted into the tumor where it creates heat that destroys cancer cells. In early tests, the procedure has proved enormously successful. Still, only about 25 percent of women would be candidates for the procedure if it eventually were approved for widespread use.

Prevention

Clinical exams and mammography won't prevent breast cancer. But these important procedures can help detect cancer in its earliest stages. The sooner you receive a diagnosis, the less treatment you need, the more options you have, and the better your overall prognosis.

There's no known way to prevent breast cancer. But the following steps may help reduce your risk:

  • Eat foods high in fiber. Try to increase the amount of fiber you eat to between 20 and 30 grams daily - about twice the amount in an average American diet. Among its many health benefits, fiber helps reduce the amount of circulating estrogen in your body. Foods high in fiber include fresh fruits and vegetables and whole grains.
  • Eat plenty of fruits and vegetables. Fruits and vegetables contain vitamins, minerals and antioxidants that can help protect you from cancer. The American Cancer Society recommends five or more servings of fruits and vegetables every day. Look for deep green and dark yellow or orange fruits and vegetables, such as Swiss chard, bok choy, spinach, cantaloupe, mango, acorn or butternut squash and sweet potatoes. Also try to eat vegetables from the cabbage family, including broccoli, brussels sprouts and cauliflower. Lycopene, a nutrient found in tomatoes and other red fruits and vegetables such as strawberries and red bell peppers, may be a particularly powerful anticancer chemical.
  • Include soy foods in your diet. Some studies suggest that substances in soy may inhibit the development and growth of cancer cells. One is the isoflavone genistein, which seems to bind to estrogen receptor sites, blocking the activity of estrogen in your body. Good sources of soy include tofu, soy milk and products made with soy milk. One caution, however. If you have, or are at risk of, estrogen-stimulated cancer, it's best to limit your intake of soy until researchers know whether plant estrogens can stimulate tumor development. And although the connection between soy and tamoxifen isn't clear, it's possible soy may reduce the medication's effectiveness.
  • Limit fat in your diet. Several observation studies have reported a correlation between a high dietary fat intake and breast cancer risk. What's more, reducing the amount of fat in your diet decreases your risk of some other cancers as well as the risks of diabetes, cardiovascular disease and stroke. And it helps you maintain a healthy weight, which also reduces your risk of breast cancer. It's a good idea to limit your fat intake to less than 35 percent of your daily calories, with no more than eight percent to 10 percent coming from saturated fats.
  • Limit red meat. The National Cancer Institute has linked consumption of red meat - beef, pork and veal - to an increased risk of several types of cancer, including breast cancer. One study found that the risk of breast cancer doubled in postmenopausal women who ate three ounces of red meat a day as compared with women who ate one ounce or less of red meat daily. Instead, emphasize fish, especially fatty fish such as salmon - their omega-3 fatty acids may help prevent breast cancer.
  • Limit alcohol. Try to limit your alcohol intake to no more than one drink a day. A recent study suggests that taking folic acid might help reduce the risk of breast cancer in women who consume moderate amounts of alcohol.
  • Stay physically active. The Nurses' Health Study, a long-term study of more than 120,000 female nurses, found that women who exercised for at least one hour a day reduced their breast cancer risk by 18 percent. Those who exercised for 30 minutes every day reduced their risk by 10 percent. Walking was found to be as effective as more vigorous types of exercise. Other studies have shown that women who exercise consistently for at least 10 years of life - whether in adolescence or adulthood - can cut their risk of cancer by as much as 75 percent. A good place to start is to aim for at least 30 minutes of exercise on most days. If you haven't been active before, start out slowly and work up gradually. Try to include weight-bearing exercises such as walking, jogging or dancing. These have the added benefit of keeping your bones strong.
  • Maintain a healthy weight. There's a clear link between weighing more than is healthy for you and breast cancer. The risk is greatest if you gain weight later in life, especially after menopause.
  • Avoid exposure to pesticides. The molecular structure of some pesticides closely resembles that of estrogen. This means they may attach to receptor sites in your body. Although studies have not found a definite link between most pesticides and breast cancer, it is known that women with elevated levels of pesticides in their breast tissue have a greater breast cancer risk.
  • If you're at high risk, ask your doctor about tamoxifen. The hormonal drug tamoxifen may reduce the risk of breast cancer in women who are at high risk of the disease. The largest study of tamoxifen to date showed that tamoxifen decreased the risk of developing breast cancer by about 50 percent during the five years of the study, although the risk of dying from the disease was not reduced. In addition, tamoxifen has other risks, including an increased chance of developing endometrial cancer, blood clots and cataracts. Only women at high risk of breast cancer are candidates for tamoxifen as a risk-reducing agent. Even then, you'll need to weigh the costs and benefits carefully with your doctor.

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