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:
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.
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 testsIf 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 testsStaging 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.
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.
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.
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:
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 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 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:
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-
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.
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.
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: