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CancerLynx - we prowl the net
February 28, 2000

Frequently Asked Questions About Breast Cancer
Pamphlet courtesy of WomanKind Breast Center at St Mary's Medical Center
(415) 750-5848

Note: This information was adapted from interviews with Breast Cancer Panel physicians.

Questions About Mammography
Questions About Surgery
Questions About Reconstruction

Questions About Follow-Up and Monitoring
General Questions About Breast Cancer
Questions About DCIS (Ductal Carcinoma In Situ)

Questions About Radiology
Questions About Chemotherapy
Questions About Tamoxifen (Novaldex)

Questions About Pregnancy and Fertility
Questions About Genetics
Questions About Diet and Lifestyle

Questions About Mammography
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1. Since I was able to feel a lump in my breast, why didn't it show up on the mammogram?
The most likely explanation for this occurrence is that the tumor was hidden in the middle of glandular tissue. Another explanation is that the mammographer did not see it because it was very small or subtle. Another possibility is that some cancers do not form lumps which would show up as a spot on the mammogram. Infiltrative cancers are more spread out. Many, many cells are spread out over an area and are not visible on mammogram. Another explanation is that some tumors are confined to the skin of the nipple and won't show up on mammogram.
2. What is a microcalcification?
Calcification represents precipitated calcium salts from the blood that leach out in areas in which there is necrotic (dead) tissue. The calcium then literally, precipitates out in the dead tissue. Other calcifications are calcium salts that are picked up by certain secretions made by cancers.
3. What causes benign calcifications?
They are produced by secretions of the duct system of the breast- rarely by necrosis(waste product of dead cells). The breast normally secretes all the time, even when the woman is not lactating or pregnant and even if she's never been pregnant or never breast fed. Some of the proteins are like milk proteins but it's not milk. But some of these proteins, as they become denatured (decomposed) in a duct, will pick up calcium salts -- will leach out calcium salts from the blood and these are called calcifications.
4. What is a core biopsy ?
The core biopsy is a procedure that takes a sample of your breast lump. It uses a tiny cylinder (the width of an 11-18 gauge needle- about the sized used when you donate blood) to withdraw biopsy material. In 1989 a powerful spring was added to the coring needle. This produces a biopsy that is much more efficient and obtains a much better specimen than a Fine Needle Aspiration (FNA). The FNA is mostly used now to distinguish cysts (fluid containing lumps) from solid lumps but not for diagnosing cancer.
5. What is a Mammotome?
The Mammotome is a new instrument for breast biopsy that was approved by the FDA in 1995. It is a mini scalpel (surgical knife blade) that is within the core biopsy equipment. The Mammotome has a very sharp blade on its edge that whirrs around. The desired specimen is then suctioned out by a vacuum system. The advantage of the Mammotone over the traditional core biopsy is that the Mammotome can obtain bigger samples. The Mammotome biopsy is also performed faster and with only one needle insertion which aids in the comfort of the patient.
6. What is a stereotactic biopsy?
Stereotactic is a general medical term that means using multiple images to direct a mechanical arm. Thus a core biopsy as well as a Mammotome would be considered stereotactic because they are both directed by multiple images of the breast.
7. What is a needle localization (needle loc)?

A needle localization is used when there is not a palpable (feelable) lump. A fine needle is inserted into the breast, directed by the mammogram where the questionable area is visible. The surgeon then knows which area needs to be removed. Needle localization serves as a marker for the surgeon. This technique is used for both biopsy and removal.

Questions About Surgery
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1. How wide should the margin of safety be for my tumor excision?
For invasive breast cancer a clean (cancer-free) margin of two or three millimeters is sufficient. In DCIS (Duct Carcinoma In Situ) it needs to be larger depending upon the type of DCIS. Generally, we recommend clear margins of 10 millimeters (one centimeter) although that's difficult to achieve. (See section on DCIS for further explanation).
2. After lumpectomy if the margins still have cancer cells in them would I then need a mastectomy?
No, a re-excision will often be sufficient to obtain clear margins.
3. If it's been re-excised, and the margins are still not clear will I then need a mastectomy?
Not necessarily. For invasive breast cancer, radiation therapy may be sufficient especially if the tumor is low grade and the margins are small but not transected (cut through). In this case very close follow up is mandatory in order to detect a recurrence at a very early stage. Also, in a woman with a larger breast, enough breast tissue may be available to perform a second re-excision and still have an acceptable cosmetic outcome.
In DCIS, if the margins are not adequate, radiation therapy may be considered depending upon the margin size and grade of the tumor. As with invasive cancer, in a woman with a larger breast, a second re-excision may be done for DCIS. There are times, however, when mastectomy may be needed for the best local control.
4. Why do I need a lymph node sampling?
A lymph node sampling (or dissection) assesses the potential of the cancer to recur systemically (spreading throughout the body) and advises doctors on further treatment needed after surgery (such as chemotherapy). Lymph nodes are removed from the axilla which means armpit, thus the term Axillary Lymph Node Dissection
5. How many nodes will be sampled (removed)?
Each patient is different. An area of fatty tissue under the armpit is removed. This pad of tissue contains varying numbers of nodes in each patient- generally 5-20. It is not known how many nodes are removed until the pathologist dissects the pad of tissues in the laboratory. There are a total of three levels of axillary lymph nodes. Level one nodes refer to nodes below the pectoralis minor muscle. These are the nodes closest to the breast. In a traditional Lymph Node Dissection, level 1 and 2 are removed. Level three nodes are rarely removed in the United States.
6. What is a Sentinel Node or Blue Node procedure?
This is a new procedure that may replace lymph node removal in patients who have a low risk of having any positive (cancer-bearing) lymph nodes. A radioactive or blue dye is injected around the tumor (or tumor site if the tumor has already been removed for biopsy). The dye is traced to the first node (sentinel node) closest to the tumor site, that node is removed and examined for signs of cancer cells. If the sentinel node is free of cancer cells it is very likely that the rest of the nodes are also free of cancer. Therefore the patient may not need a traditional lymph node removal.
7. How long do I need to stay in the hospital for my lymph node dissection?
If only sentinel node dissection occurs, then you can leave the hospital the same day of surgery. For other lymph node dissection procedures an overnight stay is generally recommended.
8. What are the short term and long term side effects of lymph node dissection?
Short term side effects include soreness, stiffness and seroma. A seroma is a mass caused by the localized accumulation of serum, or clear fluid, within a tissue or organ. Long term side effects include lymphedema and numbness under the arm. Lymphedema is an accumulation of fluid that may collect in the arm when lymph vessels are removed. This can cause the arm to swell and become disfigured and painful.
9. What is the risk of lymphedema and how can I prevent it?
The risk of lymphedema is about 3-5%. We will give you an information sheet that describes 18 steps that can be taken to prevent lymphedema.
10. Isn't mastectomy the most secure treatment for breast cancer or DCIS?
Generally mastectomy and lumpectomy with radiation are equally effective in terms of long-term survival. Women who have lumpectomy (with radiation) will need careful follow-up to detect local recurrence in the breast. But even if the woman has a recurrence her survival rate is the same as the woman who had a mastectomy. (See General Questions About Breast Cancer)
11. Are there any advantages offered by a breast surgeon vs. a general surgeon? How do I know if someone is a breast surgeon?
Breast surgeons are generally more up-to-date on the current literature and techniques used in breast cancer treatment. Ask the surgeon how much of his or her practice is devoted to the breast. Also ask the physician if she or he does a lot of close follow-up on patients at high risk (as opposed to a physician who just performs surgery).
12. Would multi-stage surgeries contribute to the spread of cancer?
No. Neither do needle biopsies. Multi-stage refers to the practice of performing one surgery at a time, for example, first the biopsy would be performed and then the mastectomy or lumpectomy would be performed at another time. Multi-stage surgeries can sometimes lead to more information and better decision making.

Questions About Reconstruction
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1. Can I have immediate reconstruction?
In almost all cases, the answer is yes. Immediate reconstruction will usually provide the best aesthetic and psychological outcome. The reasons why immediate reconstruction is generally preferable are:
a. It is possible to save more skin when immediate reconstruction is done. A more natural breast can be reconstructed, especially with the TRAM Flap procedure.
b. Because more skin is saved with immediate reconstruction, more of the skin sensation of the breast can be preserved. (Nipple sensation will be lost in any event because the nipple must be removed.) A new nipple and areola, without sensation, can later be created.
However, in the following circumstances immediate reconstruction is not possible or advisable:
a. The tumor is very large and has invaded areas beyond the breast
b. It was not possible for the surgeon to remove the entire tumor
c. A woman or her physician may prefer that chemotherapy be administered before breast reconstruction. Some physicians feel that healing of the reconstruction may be compromised by the immunosuppressive effects of chemotherapy.
2. What is the TRAM Flap procedure?
TRAM means Transverse Rectus Abdominus Myocutaneous Flap.
In simple terms:
Transverse - because the abdominal skin and fat used in the reconstruction is removed in a side-to-side fashion.
Rectus Abdominus - refers to the muscle/s that must be taken with the skin and fat to nourish the tissue.
Myocutaneous - means both muscle and skin are utilized. This is a type of reconstructive surgery of the breast following mastectomy, uses skin and fat from the belly left attached to abdominal muscle/s. The skin/fat tissue must remain attached to its original site, to retain its blood supply. The entire flap, consisting of the skin, fat, and muscle, is tunneled underneath the abdominal skin to the chest, creating the newly reconstructed breast. Later, a new nipple is made with skin on the chest, and an areola is tattooed around the nipple. This creates a very natural-looking breast. Complete recovery from the surgery takes about six weeks. Flap surgery is more complex than implant surgery.
3. What are the side effects of removing abdominal muscle in the TRAM Flap procedure?
Since your rectus abdominis muscle(s) are removed, you may no longer be able to do conventional sit-ups. However, since the abdominal wall contains many other muscles and you have only lost 1 or 2, the other muscles can be retrained to take over some of the function of the rectus abdominis. It is important to keep the remaining abdominal muscles strong in order to avoid future back problems.
4. How much muscle is removed?
The entire rectus abdominis is used to reconstruct one breast. Sometimes both rectus muscles are needed, even to reconstruct one breast. In the case of a double mastectomy both muscles must be used to create two breasts.
5. Why does the surgeon need to use the muscle? Why can't he or she just use the fat?
The muscle contains the arteries and veins which provide life sustaining blood to the skin and fat.
6. Will a TRAM flap affect athletics or my ability to walk?
It will not affect your ability to walk. If you are very athletic you should discuss the procedure with your surgeon.
7. What is a "free-flap"?
The "free-flap" is a technique which actually detaches tissue from one part of the body with the arteries and veins intact and transplants it to the chest. Microsurgical techniques are then used to suture the blood vessels to vessels on the chest to provide blood. This procedure requires the skills of a plastic surgeon who is experienced in microvascular surgery.
8. What about breast implants?
A simpler operation for breast reconstruction is to use tissue expanders and breast implants placed under the chest muscles. Tissue expanders are special implants that can be inflated over a period of several weeks to several months by painlessly injecting them with saline. Over a period of time they slowly fill, increasing in size. Once they get to the appropriate size, they are exchanged for regular, permanent breast implants.
9. How will I be monitored for recurrence if I have reconstruction?
You should have a clinical breast exam every six months to check for local recurrence. You should have one mammogram several months after your TRAM flap reconstruction to check for fat necrosis (dead tissue). After that there is no need for a mammogram in the reconstructed breast. A recurrence would be extremely rare. However, your other breast should still be checked by mammogram on a regular basis. The frequency will depend on your diagnosis.
10. Is reconstruction possible to do after radiation? For example, if I have a recurrence several years after I was treated with lumpectomy and radiation, can I have a mastectomy with reconstruction?
You can successfully have a flap procedure (such as a TRAM Flap) after radiation. Breast implants may have a higher rate of complications following radiation because of microscopic damage to the blood vessels of the skin.

Questions About Follow-Up and Monitoring
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1. Now that I have breast cancer or DCIS how often do I need a mammogram?
For DCIS, you should have a mammogram every 6 months for two years, after that a mammogram should de done yearly. For invasive cancer, if you had a lumpectomy have a mammogram every six months for two years, then yearly. If you had a mastectomy have a mammogram once a year.
2. Now that I have breast cancer or DCIS how often do I need a clinical breast exam ?
Your breast surgeon and radiation oncologist should examine your breasts every three months for two years then every 6 months indefinitely.
3. How often should I do breast self -exam?
Once a month. Breast self-exams should be done 5-7 days after your period starts. For postmenopausal women, pick the same day of every month for your breast self-exam.
4. What about ultrasound and MRI?
These tests are indicated on an individual basis. You may be eligible for a clinical trial that uses MRI for follow-up. Ask us for additional information.
5. Should I have a bone or liver scan?
This depends on your stage of cancer. Make this decision with your physician or team.

General Questions About Breast Cancer
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1. What is the difference between the recurrence rate and the survival rate?
Survival rate refers to how long the patient will live and does not take into consideration whether or not the patient has recurrences. The recurrence rate represents recurrences in the breast, as well as metastases (spread of the cancer from original site to a distant site) elsewhere in the body. There are two aspects of breast cancer; the local control and the distant metastases. A recurrence in the breast, generally does not affect survival. On the other hand, when we use the term recurrence to mean metastatic events -- we're talking about disease that's outside of the confines of the breast. This may effect survival time.
2. Is the recurrence rate lower if the patient has a mastectomy?
The local recurrence rate would be lower but survival time would be the same. Very rarely a recurrence will occur in the tiny amount of breast tissue that remains after a mastectomy. Many women are concerned about the possibility of recurrence and spread of the cancer if they don't have a mastectomy. In theory, it is more dangerous to keep the breast because a recurrence has the potential to spread and become metastatic, but in reality statistics show that with good follow-up, the recurrences are caught at an early stage and survival is not affected. This has been born out in research studies comparing large numbers of women who have either mastectomy or lumpectomy and radiation- the survival rates are the same. Radiation is also very effective in destroying any leftover cancer cells that may remain in the breast. It is so effective that some researchers are starting to recommend that women have radiation even if they have a mastectomy, especially if their tumor was large or aggressive. Currently, radiation after mastectomy is only used when there is a very high likelihood of residual disease in the breast, in the chest wall, or very high risk for recurrence.
3. Why does the cancer sometimes spread to the chest wall after a mastectomy?
When you remove the breast, metastases tend to go to areas where the blood vessels are abnormal. After a mastectomy, scar tissue remains, and the cancer is more likely to go into this scar tissue. Many women who have a recurrence in the chest wall after mastectomy, in short order, develop recurrences or metastases elsewhere. So, it's a signal that there is high potential for metastatic disease. Recurrence in the chest wall has a much heavier significance in terms of survival. Whereas, the local, in- the-breast recurrence does not jeopardize survival.
4. How can I tell if my cancer has spread beyond my breast or beyond my lymph nodes, if my lymph nodes are positive?
Its important to know that breast cancer doesn't always spread directly to the lymph nodes. It can travel beyond the breast directly through the blood stream and lymph system even if the lymph nodes are negative. That is why in some cases, especially with large or aggressive tumors, it is necessary to use chemotherapy even if no lymph nodes are affected. CT scans and bone scans should be done if your physician feels that there may be a chance of metastasis.

Questions About DCIS (Ductal Carcinoma In Situ)
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1. What are the chances of my DCIS turning into invasive cancer without any treatment?
That depends on the grade, size, and margin status of the DCIS (Ductal Carcinoma In Situ). Time is also an important factor. The rates of DCIS becoming invasive are different at 5 years, 10 years, or 15 years. This is an excellent question to ask the BCCS panel about your specific situation.
2. What are the recurrence rates after a lumpectomy?
The recurrence rates after a lumpectomy depend on the grade, size, and width of the narrowest margin. This is a good question to ask the panel about your specific diagnosis.
3. Is radiation therapy an effective treatment for DCIS?
Usually not. Evidence suggests that it is not of benefit in low-grade DCIS and has little impact on high-grade lesions. Radiation therapy does have a modest benefit for intermediate grade lesions where the margins are absolutely clear. The benefit in that group is small- about 14% at 7 years of follow-up. However, the benefit of radiation therapy only lasts a relatively short period of time. There's a great deal of benefit for the first 5 years. But, between 5 and 10 years, the benefit wears off. During the next 5 years it rises rapidly and at 10 years, the results starts to approach those of lumpectomy alone. Radiation works better on highly active metabolic tissue such as invasive cancer.
4. How long does it take DCIS to develop?
Some forms of DCIS are present for years in the breast without changing. Some forms of DCIS are associated with subsequent invasive growth after 4 to 8 years. There are instances in which there is a small area of microcalcification, which had been thought to be benign and was followed for 5 or 6 years. And then, all of a sudden, something changes. Little spiculations grow out of it. Spiculations are markings with little spikes on them. These indicate the presence of the cancer. So, we can document, in retrospect, that this cancer was present as an in situ cancer for 5 or 6 years, and then invasive cancer developed from it.
5. How long would it take DCIS to show up on my mammogram as microcalcifications?
No one knows that. We do know that, on the basis of the appearance of microcalcifications, that sometimes DCIS can appear to grow very rapidly. We don't know if they're really growing rapidly or that simply more of the lesion is showing calcification -- because the calcification doesn't always occur in every in situ cancer. Sometimes, the calcification may mark only a portion of the tumor. Sometimes, it doesn't mark any of it, even when necrosis (cell degeneration) is present.
6. Is it true that DCIS will not always be detected by a mammogram?
Yes, if the DCIS is not marked by microcalcifications it will not show up.
7. Why do you need such large surgical margins for DCIS?
With invasive cancer, if we remove most of it but there's a little bit left, radiation generally can destroy that. But with DCIS, you're not destroying the cancer completely and its generally resistant to radiation therapy. In many cases, you don't touch it and so its important to have larger margins around the DCIS areas..
8. Is it safer to have a mastectomy for my DCIS?
The difference in survival between breast conservation for DCIS and mastectomy for DCIS is 1% after 15 years of follow-up -- 1% survival advantage for patients who have mastectomy. So, there's not a lot of incentive to choose a mastectomy.
9. Is age a factor in recurrence?
Yes, particularly in women under 40 years of age, in both DCIS and invasive cancer, younger women have a higher recurrence rate.

Questions About Radiology
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1. When is radiation an appropriate treatment?
Radiation is usually done after the tumor is removed by lumpectomy. Radiation is done to prevent spread of tumor cells in the breast that may have been left over and to prevent local (in the breast), recurrence of cancer. Radiation is also done after a mastectomy if there is a high risk for chest wall cancer. Recent studies may indicate that there may be some benefit to routine administration of radiation to the chest wall after mastectomy.
2. What are the short term side effects of radiation therapy?
The short term side effects of radiation therapy are a sunburn-like reaction in the area that was irradiated. The irradiated area may be pink, irritated, or itchy. There may be moist desquamation in a small area under the arm and under the breast. Moist desquamation is a condition whereby the skin sheds and becomes moist because the area under the arm and breast is moisture-producing. These side effects will occur in the third week of radiation and will last for the duration of treatment. Constitutional side effects include mild appetite suppression, and mild fatigue, usually occurring in the 2nd or 3rd week and lasting until the end of treatment or possibly a few weeks or months beyond in some patients. Most patients are able to continue to work while being treated. Approximately 1-3% of patients may get radiation pneumonitis which is an inflammation of the lining of the lungs. It is successfully treated with steroids such as cortisone. If the lymph nodes are not irradiated there is less chance of pneumonitis. 1-3% of patients will get spontaneous fracture of the rib in areas that have been irradiated. This may not be felt at all but will show up on xray.
3. What are the long term side effects of radiation therapy?
A long-term side effect is radiation fibrosis which is a scarring of the lung caused by a small part of the lung being irradiated during treatment. It usually does not cause symptoms but rarely it may cause shortness of breath or cough. Almost all patients will get some minimal degree of radiation fibrosis seen on xray, but only 1-3% will have symptoms.
4. Can radiation cause cancer later in my life?
Even more rare than the above side effects is the chance of developing a secondary malignancy. Approximately 1% of patients will develop a soft tissue sarcoma (a form of cancer). This may develop 10-20 years after treatment. The first signs would be skin changes usually at the site of the previous radiation. Report any skin changes or masses to your radiation oncologist who will be following you closely after your treatment. We want to emphasize that a secondary cancer is extremely rare and that the benefits of radiation therapy far outweigh the very small potential for secondary cancers.
5. Will my hair fall out as a result of radiation therapy?
The hair on your head will not fall out, but you may lose some hair under your arm.
6. How long does treatment last?
The treatment is given five days per week for 7 weeks. During the first 5 weeks the entire breast is irradiated. During the last two weeks the lumpectomy site alone is given a booster dose.
7. What is the usual dose ?
The usual dose is 4,500-5,000 rads. The usual dose to the booster site is 1500-2,000 rads. The total dose of treatment is 6500 rads.
8. How long after radiation should I wait to get pregnant?
At least one year.
9. How long a period after diagnosis with breast cancer can I safely wait before beginning radiation treatment?
It's important to begin radiation therapy within 4 months of diagnosis. After that the effectiveness of radiation treatment may decline.

Questions About Chemotherapy
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1. What are the usual indications for chemotherapy?
In general, patients receive chemotherapy if they have positive lymph nodes or large and or aggressive invasive tumors. However, recently there is a general trend toward treating women with chemotherapy who have smaller and less aggressive tumors. This is because studies are showing better outcomes when chemotherapy is included in the treatment plan. For example, in previous years patients would be given chemotherapy if their tumor size was greater than 3 centimeters ( a centimeter is about ½ inch.). But now studies are showing that there may be some benefit to using chemotherapy if the tumor is 1 centimeter or greater if the tumor is aggressive or shows negative characteristics such as a poorly differentiated tumor, high S phase, HER2/neu positive, or hormone receptor negative (estrogen and/or progesterone). (Please see our patient information sheet called Breast Cancer Terminology for definitions of the previous terms). Also, patients with local advanced disease (growth of the cancer into the chest wall, for example) definitely need chemotherapy. Finally, chemotherapy is indicated in women with metastatic disease- particularly either lung or liver metastases, or in women who are showing signs of progressive disease. Whether or not to use chemotherapy is a highly individual decision and an important reason for obtaining a second opinion from a medical oncologist or panel that includes medical oncologists.
2. When is chemotherapy administered?
If the tumor is relatively small, a lumpectomy or mastectomy is performed first followed by chemotherapy. In many cases, the biopsy that originally diagnosed the cancer, also served as lumpectomy to remove the cancer. If the surgical margins surrounding the tumor were adequate, that is free of cancer, then a patient can procede to chemotherapy. If the margins are too small or transected (cut through), then a re-excision may be needed before chemotherapy is administered. (Please see section on Surgery). Sometimes chemotherapy is administered before surgery in order to shrink a large tumor. This is called neo-adjuvant chemotherapy. This may make it possible for a woman to have a lumpectomy rather than a mastectomy. Some patients (usually stage III patients who's tumors are 5 cm or larger) are given the sandwich method. First chemotherapy is given, for two to three cycles followed by surgery. Then three cycles of chemotherapy and finally radiation therapy. Then an additional course of chemotherapy is given.
3. What types of chemotherapy are available for breast cancer?
There are various single agents and combinations of drugs that work against breast cancer cells. The most commonly used drugs are: Cytoxan (cyclophosphamide), Methotrexate, 5 fluorouracil (5 Fu), Adriamycin (doxorubicin), Taxol (paclitaxel) and Taxotere (docetaxel). Frequently used combinations are:
AC - Adriamycin, Cytoxan
CMF - Cytoxan, Methotrexate, 5 fluorouracil
More recently, the taxanes - Taxol, or Taxotere, are being used especially when a patient has a large number of positve lymph nodes or her cancer is resistant to Adriamycin. New regimens being developed are incorporating Taxol or Taxotere, with Adriamycin.
For metastatic breast cancer other agents are also used such as: mitomycin-C, vinblastine (Velban), and its analog, Navelbine. Single agents (one drug alone instead of a combination) are often given to patients who have metastatic disease for the purpose of palliation ( relieving some symptoms even though a cure may not be possible).
4. What is meant by adjuvant chemotherapy?
Chemotherapy that is given in conjunction with local treatments such as surgery is referred to as adjuvant therapy.
5. How will my chemotherapy be given to me?
Most chemotherapy is given intravenously (in the veins). In patients who will be receiving several months of chemotherapy, the use of central venous access may be advisable. This is a port that is placed under the skin surgically and is attached to a catheter that goes directly to the central circulation of the body. You won't need to be stuck each treatment, because the drug is inserted into the port. It is particularly important if Adriamycin is being administered because of its irritability to the veins. Other agents, such as the taxanes (Taxol or Taxotere) and Navelbine can also cause irritation to the veins. However, these indwelling catheters have a small risk of infection and thrombosis (blood clots).
6. Are there any oral chemotherapy drugs?
There is oral Xeloda, which is usually used in advanced cases. There are now analogs of methotrexate, which are oral, that are being developed.
7. What are the short term side effects of chemotherapy?
Most commonly, chemotherapy affects the bone marrow. Cytoxan or Cytoxan/Adriamycin, usually affect the bone marrow between days 10 and 14. Recovery occurs by day 15. In the taxanes, (Taxol or Taxatere), bone marrow suppression usually occurs at day 8, and then there is usually recovery by day 10 or 11. Usually, chemotherapy is repeated every 21-24 days after patients have recovered from all side effects (bone-marrow suppression, mucositis, and diarrhea). CMF chemotherapy also causes bone marrow suppression, usually in the second week. Recovery usually takes place by day 21 or before. Adriamycin, in particular, causes hair loss, as do the taxanes. Adriamycin can cause damage to the heart. Congestive heart failure, irregular heart beats and other cardiac toxicities may occur when the patient receives a cumulative dose greater than 500 mg/m2. Therefore medical oncologists make every effort to keep the dose as low as possible within the range of effectiveness. Continuous (slow) infusion of Adriamycin also reduce the cardiac toxicity. There are now cardiac-sparing medicines available that help to protect the heart when used with Adriamycin. There are also analogs (related compounds) being developed that are less cardiotoxic. Stomatitis (inflammation of the mucous membranes of the mouth), mucositis (inflammation of the lining of the mouth and gastrointestinal tract), and diarrhea are particularly prevalent with drugs like methotrexate, 5-fluorouracil, and Adriamycin.
8.What are the long term effects of chemotherapy?
Adriamycin can rarely cause long term damage to the heart- usually congestive heart failure. As mentioned above this side effect is dose dependent and strong efforts are now made to limit the dose and method of administration to avoid cardiac toxicity. Taxol and Navelbine can cause neuropathy (damage to the nerves) that involves the hands and feet. The symptoms are usually mild but can be severe. These effects are dose-dependent and therefore limit how high the dose can go. Neuropathy is usually reversible, but often persists for long periods of time.
9. Are side effects from chemotherapy reversible?
Bone marrow suppression can be more profound after several cycles, but is reversible. Cardiac toxicity, unfortunately, is not reversible. Alopecia (hair loss) is reversible and the hair often grows in curly! (chemo curls). Mucositis and diarrhea are reversible toxicities.
10. Can chemotherapy cause secondary cancers, perhaps many years later?
There is a very small risk of developing a secondary malignancy, particularly leukemia, secondary to alkylating agents such as Cytoxan. Also, very rarely, various solid tumors have been noted. But it is important to keep in mind that the survival benefits of chemotherapy far outweigh the small risk of secondary cancers.
11. What is a cold cap and do you recommend it to prevent hair loss during chemotherapy?
A cold cap is a device that is placed over the patient's head during chemotherapy to prevent hair loss. In general it's not very effective and there has been some question about whether the chemotherapy is being prevented from penetrating the area covered by the cap. There is some recent data, however, to suggest that there may be some benefit to using a cold cap to prevent Alopecia (hair loss) when using Taxol.
12. What is a Bone Marrow Transplant?
A Bone Marrow Transplant is a procedure in which a patient's bone marrow is replaced after being destroyed by high doses of chemotherapy. Bone marrow is the soft, spongy material found inside bones. IT contains stem cells, the immature cells that develop into white and red blood cells and platelets.* Nowadays the procedure is performed by removing the stem cells from the patient's circulating blood. After the high dose chemotherapy is given the patient's own stem cells are transfused back into the circulation. This is called Peripheral blood stem cell transplantation.
13. What are the indications for a bone marrow transplant or stem cell support?
Patients who have very aggressive disease and who are not responsive to conventional chemotherapy are often considered for bone marrow transplantation. These are generally patients who have greater than 10 positive nodes or patients with metastatic disease. A recent study has called into question the effectiveness of bone marrow transplant verses an aggressive regimen of chemotherapy which includes taxanes. Be sure to consult several experts before making the decision to have a bone marrow transplant
14. How is nausea controlled during chemotherapy? What are the commonly used anti-nausea drugs, how are they used, and how do they differ?
Nausea and vomiting are usually well controlled by the antiemetic medications that we have available. Common anti-nausea drugs given IV are: Zofran (ondansetron) and Kytril (granisetron). Other antiemetics used either orally, intravenously or by rectal suppository are Ativan (lorazepam), Compazine (prochlorperazine), and Reglan (metoclopramide). Marinol (dronabinol) and marijuana are particularly helpful in young patients. The new serotonin reuptake inhibitors, what are called H-3 blockers, have been extremely helpful for the control of nausea and vomiting.
15. What is the HER2/neu oncogene and how does Herceptin help?
In 25 to 30% of women with metastatic breast cancer, there is a genetic alteration in the HER2 gene. HER2/NEU is an oncogene that makes proteins that receives signals from growth hormones. This protein helps tumor cells spread therefore if your tumor is HER/neu positive it may indicate an aggressive tumor. If your tumor is HER/neu positive, you could be eligible for a new treatment that interfers with this gene, called Herceptin. Herceptin is one of a biological class of drugs known as monoclonal antibodies.

Questions About Tamoxifen (Novaldex)
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1. When is Tamoxifen an important treatment?
There is a substantial benefit in taking Tamoxifen in a postmenopausal female who is ER and PR positive (Estrogen/Progesterone receptors), and for recurrent disease (particularly soft tissue and bony metastasis). Response rates vary but may be at least 50% in patients who are responsive to hormonal treatments. Current recommendations for Tamoxifen usage is not to go beyond 5 years of use. It appears that benefits are obtained at 5 years, and there may be some unwanted side effects after 5 years of usage.
2. What are the side effects of Tamoxifen?
Tamoxifen (Novadex) is generally well tolerated. However, hot flashes and irritability are common. There is some concern about Tamoxifen causing malignancies such as endometrial cancer. It is important to have periodic endometrial biopsies while on Tamoxifen so that endometrial cell irregularities can be diagnosed before they become malignant. Liver cancer has also been reported rarely. We have an extensive file on Tamoxifen at the WomanKind office. We can give you lots of information so that you can make an informed decision.

Questions About Pregnancy and Fertility
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1. How long after chemotherapy should I wait to get pregnant?
Its advisable to wait at least 6 months after chemotherapy is completed before trying to become pregnant.
2. Will chemotherapy cause birth defects and should I be tested during pregnancy?
Chemotherapy can cause birth defects in the first trimester. Should amniocentesis or chorionic villus sampling be done?
3. How will I know if I am still fertile after treatment?
Generally women in their 20's and 30's are more likely to retain their fertility after chemotherapy than women in their late 30's and 40's who will often go into a chemotherapy-induced menopause. If your period returns after treatment you are likely to be fertile.

Questions About Genetics
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1. Which relatives determine my genetic risk for breast cancer?
First order relatives are the most significant. They include your mother, sisters and daughters. Second order relatives are your maternal and paternal aunts and maternal and paternal grandparents. Cousins, great-grandmothers etc don't count very much.
2. Does it matter if these relatives had breast cancer before or after menopause?
The risks are higher for pre-menopausal cancer but first order is still first order, whether its pre or post menopausal, and second order is still second order whether its pre or post menopausal.
3. Should I take a blood test for genetic predisposition?
The question is- what are you going to do with the results? Getting this information is like opening up Pandora's box, only worse, because first of all, a patient may be very unhappy with the information. And unless she's going to act on the information, it doesn't make any sense to have the test. In certain, rare circumstances, in high-risk families, who have the BRCA-1 gene, acting on the information can save a life. It doesn't always, but it can. But, for most women who may be BRCA-1 positive and who don't have a significant family history of breast cancer, we have no idea what the data means. So, they're going to make themselves unhappy. And then, say if one sister gets the test and finds that she is BRCA-1 positive and tells her sister, then her sister is going to have a number of problems. Number one: She's going to be confronted with information she basically didn't want to know -- that there's BRCA-1 in the family. Number two: She's going to have to decide whether she wants to get tested or not, and she may not want to do that. Number three: She's going to have to figure out what she's going to tell her daughters. Number four: she's going to feel miserable because then she's going to have to confront the fact that perhaps 50% of her daughters are carriers and are at risk. And she, as the mother and transmitter, is going to feel guilty for having transmitted this disease. Then, she's going to get angry at her sister for going through this whole process to begin with.
4. What are other problems with getting the gene test?
If a woman is carrying the BRCA-1 gene, her insurance company may rewrite her insurance policy to exclude her from breast cancer treatment. Then they might search their computer file for her relatives and exclude them as well. This could turn into a big mess.
5. When is it ever a good idea to do genetic testing?
When the family is clearly a high risk family -- when there are grandmothers and maternal aunts and sisters who have breast cancer at a young age -- bilateral breast cancer, ovarian cancer -- when it's clear that this is likely to be a BRCA-1 family. When there are a lot of young women at risk -- and where there have been deaths from breast cancer. When the family kind of knows it anyway and says, "Look, we need to know because my 28-year-old daughter wants to know. She could have some surgical intervention or some kind of intervention and maybe protect herself from some of the death, which is real, in our family. And I've got four daughters and maybe if two of them don't have this gene and they get married and have children, they won't pass the gene on to other people.." So, therefore, it's useful to know in that situation. And yes, we realize that they may feel guilty that they don't have the gene and their sisters do, but maybe we can get them to understand with counseling that this isn't their fault -- that none of our genetic makeup is our fault. We just inherit it. We're not responsible for our parents -- nor are they for our genes. So in a situation of a very high risk family it may be appropriate.

Questions About Diet and Lifestyle
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1. Is it important to maintain a low fat diet now that I have breast cancer?
There are no current studies showing a decrease in breast cancer recurrence rates. As for prevention of cancer, many studies have been done and the results are contradictory. A 1996 Harvard study of 335,000 women from four countries showed no change in breast cancer rate in women consuming diets of 20% fat. However, some researchers think that the crucial factor may be the diet of adolescent girls, not grown women. Critics of the study, such as Dean Ornish, say that the diet must be 10% fat or lower in order to see a reduction in breast cancer. And some studies seem to indicate that its the type of fat one consumes that's important. One study of Greek women who ate a substantial amount of olive oil in the diet had lower rates of breast cancer than the general population.
2. Can being overweight or obese cause breast cancer?
Excess pounds may predispose women to breast cancer because fat cells produce estrogen which may stimulate breast cancer. So although there seems to be no direct link between fat in the diet and breast cancer, being fat can predispose to breast cancer. The heaviest women in their 40's and 50's have twice the risk of developing breast cancer than the leanest women of the same age. However, there is no data concerning overweight and breast cancer recurrences.
3. What about a vegetarian diet?
Some vegetarian diets contain dairy products and eggs which have saturated fats similar to meat. A macrobiotic or vegan diet (no dairy or eggs) is low in fat but we have no data on these diets and breast cancer rates. Diet high in fruits and vegetables prevents many types of cancers (see below). In general there are no completed studies on preventing breast cancer recurrences with diet. All the data is from preventing primary cancer in the general population.
4. Can Tofu or other soy products prevent cancer or prevent recurrences?
Soy products may be protective against breast cancer. Protease inhibitors present in soy products suppress the production of enzymes in cancer cells which may slow tumor growth. Isoflavones block the entry of estrogen into cells, which may reduce the risk of breast cancer. We have no information about soy products preventing recurrence and some women are concerned that the phytoestrogen (plant estrogen) in soy may stimulate tumor growth.
5. What about anti-oxidants?
A diet high in fruits and vegetables, which contain high levels of antioxidants, have been shown to prevent many types of cancers. However, there are no completed studies proving lower breast cancer recurrence rates.
6. How much alcohol is it safe to drink now that I have breast cancer or DCIS?
Studies on alcohol and breast cancer are also contradictory and we don't know of any studies done on women who already have breast cancer. It appears that drinking alcohol under the age of 30 may increase breast cancer rate. In the general population of women, drinking more than nine drinks per week, seems to have a 1.6 increase in the rate of breast cancer (1 is the norm).
7. Will exercise help? What type?
Aerobic exercise has been shown to reduce breast cancer rates in women. It is not know if this is because of the reduction in body fat. Our body fat contains high levels of estrogen, which may stimulate cancer cells. Mild to moderate exercise may strengthen the immune system. As with diet, there are no studies yet demonstrating a reduction in recurrence rates in women who already have breast cancer. Of course exercise is healthy for so many reasons.

Breast Cancer Consultation Center at St Mary's Medical Center
450 Stanyan Street
San Francisco, CA 94117
(415) 750-5848

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