5   TREATMENT OPTIONS

Surgery

Most women who have breast cancer today are diagnosed with Stage 0, I, or II breast cancer. Many of these women will live a long life. Most of these women can choose:

• Lumpectomy and radiation therapy, OR
• Mastectomy.

Surgical procedures for breast cancer treatment usually require hospitalization. Under New York State law, the length of time you are in the hospital after a lumpectomy, lymph node dissection, mastectomy or breast reconstruction is up to you and your doctor. Your insurance company or health maintenance organization (HMO) cannot limit your hospital stay to less time than your doctor feels is appropriate for your case.

Studies show that both lumpectomy and mastectomy provide the same long-term survival rates. However, neither option gives you a 100% guarantee that cancer will not return at the treated site. Whichever choice you make, you will still need medical follow-up and monthly breast self-exams for the rest of your life. Here is a closer look at today's most common breast surgeries:

Lumpectomy

---

Lumpectomy

With a lumpectomy, a surgeon removes the breast cancer, a little normal breast tissue around the lump, and some lymph nodes under the arm. This procedure tries to totally remove the cancer while leaving you with a breast that looks much the same as it did before your surgery. Women who choose a lumpectomy almost always have radiation therapy as well. Radiation decreases the risk of cancer coming back in the remaining breast tissue.

Possible problems: Infection, poor wound healing, bleeding, and a reaction to the drugs (anesthesia) used in surgery are the main risks of any kind of surgery, including lumpectomy. Women may have a change in the shape of the breast that was treated.

Total Mastectomy	Modified Radical Mastectomy

Mastectomy

A mastectomythe surgical removal of the breastused to be the only treatment for breast cancer. Today a woman who has a mastectomy is likely to have either:

Total Mastectomy (also known as simple mastectomy). This surgery removes as much breast tissue as possible, the nipple, and some of the overlying skin. The lymph nodes in the armpit are not removed.

Modified Radical Mastectomy. This surgery removes as much breast tissue as possible, the nipple, the lining over the chest muscles, and some lymph nodes in the armpit.

A mastectomy is needed when:

• The cancer is found in numerous areas in the breast.
• The breast is small or shaped so that removal of the entire cancer will leave little breast tissue or a deformed breast.
• The woman does not want to have radiation therapy.

Possible problems: Infection, poor wound healing, drug reactions, and a collection of fluid under the skin are possible complications.

After a mastectomy, a woman may choose to:

• Wear a breast form (a prosthesis) that fits in her bra. (To get information on stores that have good fitters and breast forms, talk to your doctor, nurse, American Cancer Society volunteer, breast cancer organizations, and other women who have had breast cancer.)
• Have her breast reconstructed by a plastic surgeon.
• Decide to do neither.

As of January 1, 1998, health insurance policies providing medical and surgical coverage in New York State are required to pay for costs of breast reconstruction after surgery for breast cancer. If you have an existing health insurance policy, this law goes into effect the first time the policy is renewed or updated after January 1, 1998. Required payment for breast reconstruction does not apply to self-insured plans or to some plans issued by an out-of-state employer. Some plans may have restrictions as to where a woman can receive the breast reconstruction. For details of your plan, contact your insurance company or HMO. If you have questions about this law or other insurance legislation, call the New York State Insurance Department at 1-800-342-3736.

Removal of Lymph Nodes

Whether you have a lumpectomy or mastectomy, your surgeon will usually remove some of the lymph nodes under your armpit. This procedure (an axillary node dissection) is most often done at the same time as the breast surgery.

In early stage breast cancer, a new procedure called sentinel node biopsy is being studied in some medical centers. Sentinel node biopsy may or may not be appropriate for you depending on your clinical circumstances. With this procedure, a radioactive substance is injected near the site of the primary tumor a day before the surgery. A probe is then used to identify the location of the first node to absorb the radioactive liquid. This node, called the sentinel node, is removed through a small incision and biopsed. If biopsy of the sentinel node shows no malignant cells, then it is more than 97% likely that the other axillary nodes will also be disease-free. It is hoped that this technique will spare women with negative nodes from unnecessary surgery. It may also reduce the risk of lymphedema, a swelling of the arm caused by displaced lymph fluid that sometimes follows lymph node surgery.

If cancer is found in the lymph nodes, your doctor will talk to you about additional treatments. These additional therapies are designed to control and kill cancer cells that could be in other parts of your body (see Therapies).

Possible problems: Stiffness of the arm, numbness under your arm, and swelling of the arm. Physical therapy is often helpful to restore full motion of your arm.

Lymphedema. The lymph nodes in your armpit filter lymph fluid from the breast and your arm. Both radiation therapy and surgery can change the normal drainage pattern. This can result in a swelling of the arm called lymphedema. The problem can develop right after surgery or months to years later. About 5% to 20% of women develop this problem.

Treatment of lymphedema will depend on how serious the problem is. Options include an elastic sleeve, an arm pump, arm massage, and bandaging of the arm. Exercise and diet also are important. Should this problem develop, talk to your doctor and see a physical therapist as soon as possible. Many hospitals and breast clinics now offer help for this problem.

Protecting Your Arm

To avoid lymphedema or to protect your arm after treatment:

• Avoid sunburns and burns to the arm or hand.
• Have shots (including chemo-therapy) and blood pressure tests done on the other arm.
• Use an electric razor for shaving underarms.
• Carry heavy packages or handbags on the other arm or shoulder.

More Ways to Protect Your Arm

• Wash cuts promptly, apply antibacterial medication, cover with a bandage, and call your doctor if you think you have an infection.
• Wear gloves to protect your hands when gardening and when using strong detergents.
• Avoid wearing tight jewelry on your affected arm or elastic cuffs on blouses and nightgowns.

In most cases, a lumpectomy is followed by radiation therapy. High-energy radiation is used to kill cancer cells that might still be present in the breast tissue.

In standard therapy, a machine delivers radiation to the breast and in some cases to the lymph nodes in the armpit. The usual schedule for radiation therapy is 5 days a week for 5 to 6 weeks. Sometimes a "boost" or higher dose of radiation is given to the area where the cancer was found.

During treatment planning, your chest area will be marked with ink or with a few long-lasting tattoos. These marks need to stay on your skin during the entire treatment period. They mark where the radiation is aimed.

Possible problems: Side effects may include feeling more tired than usual and skin irritations, such as itchiness, redness, soreness, peeling, darkening, or shininess of the breast. Radiation to the breast DOES NOT cause hair loss, vomiting, or diarrhea. Long-term changes may include changes in the shape and color of the treated breast, spider veins, and heaviness of the breast.

Radiation after Mastectomy

There are times when radiation will be suggested after a mastectomy. It is suggested if:

• The tumor is larger than 5 cm (2 inches).
• Cancer is in many lymph nodes in the armpit.
• The tumor is close to the rib cage or chest wall muscles.

Thoughts to Remember about Radiation Therapy

You often will be alone in a room, but your radiation therapist can hear you and see you on a television screen.

The treatment lasts a few minutes. You will not feel anything.

The radiation is delivered to a small area — your treated breast.

You are NOT radioactive during or after your therapy.

You CAN hug, kiss, or make love as you did before your therapy.

Chemotherapy & Hormone Therapy

Research suggests that—even when your lump is small—cancer cells may have spread beyond your breast. Most of these cells are killed naturally by your body's immune system. When the growth of cancer cells is large enough to be detected, it means that your immune system is having difficulty fighting the cancer and needs additional help.

Help in killing cancer cells comes from two other forms of therapy chemotherapy and hormone therapy. Now, more than ever before, these treatments are chosen for your individual case: your age, whether you are still having periods, and how willing and able you are to cope with the possible side effects. These therapies are used to:

• Prevent cancer from coming back in women who are newly diagnosed with breast cancer, especially if they are at high risk for spread of the disease to other organs of the body.
• Control the disease when cancer is found in the lungs, bones, liver, brain, or other sites.
• Control the disease in women whose cancers have come back one or more times.

Chemotherapy

Chemotherapy drugs are designed to travel throughout your body and slow the growth of cancer cells or kill them. Most often the drugs are injected into the bloodstream through an intravenous (IV) needle that is inserted into a vein. Some are given as pills. Treatments can be as short as 4 months or as long as 2 years. The drugs you take will depend on the stage of the cancer at the time you are diagnosed or if the cancer returns.

Chemotherapy is usually given in cycles. You get one treatment and are given a few weeks to recover before your next treatment. The drugs most often are given in a doctor's office or in an outpatient department of a hospital or clinic.

A national study has evaluated the use of chemotherapy to shrink breast cancer tumors before surgery. While it is too early to tell if "neoadjuvant" (preoperative) chemotherapy increases survival rates, it does appear that in a number of cases, it shrinks the tumor enough so that the woman can be treated with a lumpectomy, rather than a mastectomy. This may give some patients with larger tumors the option of breast-conserving surgery.

Possible problems: The most common side effects are fatigue, nausea, vomiting, diarrhea, constipation, weight change, mouth ulcers, and throat soreness. Some drugs cause short-term hair loss. Hair WILL grow back after or sometimes during treatment.

Before you start your therapy, you may want to have your hair cut short, buy a wig, hat, or scarves that you can wear while you are going through treatment. Also, finish dental work before starting your therapy. You cannot have dental work during chemotherapy because you are more prone to infections.

Fighting Infections. Your body is less able to fight infections while you are on chemotherapy. The following steps can help you stay healthy:

• Stay away from large crowds and from people with colds, infections, and contagious diseases.
• Bathe daily, wash hands often, and follow good mouth care.
• Wear work gloves to protect hands against cuts and burns.
• If you cut yourself, keep the wound clean and covered.
• Eat a healthy diet and get plenty of rest.

Hormone Therapy

Tests are routinely done on breast cancer cells to decide if the cancer is "sensitive" to natural hormones (estrogen or progesterone) in the body. If the tests find that the cancer is "positive," it means that cancer cells may grow when these hormones are present in a tumor. You may be given a hormone blocker (a drug called tamoxifen) that will prevent your body's natural hormones from reaching the cancer. These drugs are taken daily in pill form.

Possible problems: Hot flashes, nausea, vaginal spotting. Less common side effects include depression, vaginal itching, bleeding or discharge, loss of appetite, headache, and weight gain. Studies show that there is a slight increased risk of uterine cancer and blood clots for women on this drug. You should have an annual pelvic exam and notify your doctor if you are taking tamoxifen.

Breast Reconstruction

Breast reconstructionsurgery to "rebuild" a breast is a routine option for any woman who has lost a breast because of cancer. As of January 1, 1998, New York State law requires health insurance policies that provide medical and surgical coverage to pay for reconstruction and for surgery to the other breast to obtain a good match. If you have an existing health insurance policy, this requirement does not take effect until the first time your policy is renewed or updated after January 1, 1998. Required payment for breast reconstruction does not apply to self-insured health plans or to some plans paid for by an out-of-state employer. If you have any questions about the details of your plan, talk with your insurance company. If you have questions about legislation on breast reconstruction or other insurance legislation, call the New York State Insurance Department at 1-800-342-3736.

Reconstruction will not give you back your breast. The rebuilt breast will not have natural feelings. But the surgery can give you a result that looks like a breast.

If you are thinking about reconstruction, discuss this option with a plastic surgeon before your mastectomy. Ask your surgeon for a referral to an experienced plastic surgeon. Some women start reconstruction at the same time as their mastectomy; others wait several months or even years. Your body type, age, and cancer treatment will determine which reconstruction will give you the best result.

Reconstruction with Implants

Implants are plastic sacs filled with silicone (a type of liquid plastic) or saline (salt water). The sacs are placed under your skin behind your chest muscle.

There are concerns about silicone-filled implants.

• Manufacturers and recent studies report that the silicone-filled implants are safe. They say that the safety record of implants is based on 30 years of experience with more than one million women.
• However, lawsuits have been filed for women who claim that the implants caused them to develop immune system disorders (such as lupus, scleroderma, and rheumatoid arthritis) and other complications.

The Food and Drug Administration (FDA) reports that implants do not cause cancer. There also is no scientific evidence to link implants with immune system disorders. But the FDA states that more studies are needed before a final decision can be made.

To help determine the short-term safety and effectiveness of silicone implants, the FDA has authorized a large-scale study by an implant manufacturer, the Mentor Corporation. The study is open to women who need breast reconstruction for medical reasons, such as breast cancer surgery or a birth defect. Currently, these women are the only patients allowed to receive silicone breast implants. Each woman must be referred to the study by her surgeon and will be followed for five years. To learn more about this study, call Diane Hart at 1-800-MENTOR-8 (1-800-636-8678).

After Mastectomy	After Reconstruction with Implants

Studies also are looking at saline-filled implants, but these implants cause less concem. Under current FDA rulings, saline-filled implants are available to anyone who wants them.

If major problems do exist with either type of implant, they appear to affect a small number of women. For this reason, women who have a mastectomy can still choose to have their breast rebuilt with either a silicone or saline implant.

Possible problems: It is natural for scar tissue to form around an implant. Sometimes this scar may shrink, causing the implant to ball up and feel firm. This can cause pain or a deformed breast. This scar tissue may have to be treated with surgery. Breakage of the implant's cover is another possible problem.

This flap of muscle, skin, and fatty tissue is moved, still connected to its blood supply. It is shaped to form a new "breast."

---

Reconstruction with Tissue Flaps

Muscle, fat, and skin from another part of the body can be moved to the chest area, where it is shaped into the form of a breast. This tissue can be taken from the:

• Lower stomach area (rectus abdominis muscle flap)
• Back (latissimus dorsi muscle flap)
• Buttocks (gluteus muscle flap).

Possible problems: There are larger wounds. It takes longer to recover. If there is a poor blood supply to the flap tissue, part or all of the new breast can be lost. Infection and poor wound healing are possible problems. Choose a plastic surgeon who has been trained in this procedure and has performed it successfully on many other women.

With most of these extra surgeries, you can go home the same day as the operation.

Complementary Therapies

Persons living with cancer sometimes want to explore complementary therapies in addition to their medical treatment. These therapies are often not proven by scientific studies. Some women feel that they have benefited from some of these therapies.

Complementary therapies include acupuncture, herbs, biofeedback, visualization, meditation, yoga, nutritional supplements, and vitamins. If you decide to try these therapies, discuss the side effects and data on their value with your doctor. Also, be aware that these therapies may be expensive and most are not paid for by health insurance.