women s health issues
Breast Cancer
Treatment of Breast Cancer
Surgery Radiation therapy Systemic (body-wide) chemotherapy Hormone blockers (medications that affect hormones) Treatment for breast cancer begins after the woman’s condition has been thoroughly evaluated. Treatment options depend on the stage and type of breast cancer and the receptors that the cancer has. However, treatment is complex because the different types of breast cancer differ greatly in characteristics such as growth rate, tendency to spread (metastasize), and response to various treatments. Also, much is still unknown about breast cancer. Consequently, doctors may have different opinions about the most appropriate treatment for a particular woman. The preferences of a woman and her doctor affect treatment decisions (shared decision-making). Women with breast cancer should ask for a clear explanation of what is known about the cancer and what is still unknown, as well as a complete description of treatment options. Then, they can consider the advantages and disadvantages of the different treatments and accept or reject the options offered. Doctors may ask women with breast cancer to participate in research studies investigating a new treatment. New treatments aim to improve the chances of survival or quality of life. Women should ask their doctor to explain the risks and possible benefits of participation, so that they can make a well-informed decision. Treatment usually involves surgery and often includes radiation therapy and chemotherapy or hormone blockers. Sometimes a woman can choose whether surgery will involve removing part or all of one or both breasts. Women may be referred to a plastic or reconstruction surgeon, who can remove the cancer and reconstruct the breast in the same operation. The cancerous tumor and varying amounts of the surrounding tissue are removed. There are two main options for removing the tumor: Breast-conserving surgery plus radiation therapy Removal of the breast (mastectomy) For women with invasive cancer (stage I or higher), mastectomy is no more effective than breast-conserving surgery plus radiation therapy as long as the entire tumor can be removed during breast-conserving surgery. In breast-conserving surgery, doctors remove the tumor plus some surrounding normal tissue to reduce the risk that tissue that may contain cancer is left behind. Before surgery, chemotherapy may be used to shrink the tumor before removing it. This approach sometimes enables some women to have breast-conserving surgery rather than mastectomy. Breast-conserving surgery leaves as much of the breast intact as possible. When considering the type of surgery, it is more important for doctors to be sure they remove the whole cancer than to risk leaving tissue that may contain cancer. For breast-conserving surgery, doctors first determine how big the tumor is and how much tissue around it (called margins) needs to be removed. The size of the margins is based on how big the tumor is in relation to the breast. Then the tumor with its margins is surgically removed. Tissue from the margins is examined under a microscope to check for cancer cells that have spread outside the tumor. These findings help doctors decide on whether further treatment is needed. Various terms (for example, lumpectomy, wide excision, quadrantectomy) are used to describe how much breast tissue is removed. Breast-conserving surgery is usually followed by Radiation Therapy for Cancer . The main advantages of breast-conserving surgery are the possibility of preserving breast tissue and how the breast appears after surgery. When the tumor is large in relation to the breast, this type of surgery is less likely to be useful. In such cases, removing the tumor plus some surrounding normal tissue means removing most of the breast. Breast-conserving surgery is usually more appropriate when tumors are small. In about 15% of women who have breast-conserving surgery, the amount of tissue removed is so small that little difference can be seen between the treated and untreated breasts. However, in most women, the treated breast shrinks somewhat and may change in contour. If either breast-conserving surgery or mastectomy is an option, a woman should consider each option. Some women prefer breast-conserving surgery because they feel that losing a breast would be a very difficult emotional and physical experience and that breast-conserving surgery helps preserve body image. Other women prefer mastectomy because they feel more comfortable having all the breast tissue removed or because if they have a mastectomy, they may not need radiation therapy. Chemotherapy, given to shrink the tumor before removing it, may enable some women to have breast-conserving surgery rather than a mastectomy. Mastectomy is the other main surgical option. There are several types. In all types, all breast tissue is removed, but which other tissues and how much of them are left in place or removed vary by type: Skin-sparing mastectomyleaves the muscle under the breast and enough skin to cover the wound. Reconstruction of the breast is much easier if these tissues are left. The lymph nodes in the armpit are not removed. Nipple-sparing mastectomyis the same as skin-sparing mastectomy plus it leaves the nipple and the area of pigmented skin around the nipple (areola). Simple mastectomyleaves the muscle under the breast (pectoral muscle) and the lymph nodes in the armpit. Modified radical mastectomyconsists of removing some lymph nodes in the armpit but leaves the muscle under the breast. Radical mastectomyconsists of removing the lymph nodes in the armpit and the muscle under the breast. This procedure is rarely done now unless the cancer has invaded the muscle under the breast. Doctors assess lymph nodes to determine whether cancer has spread to the lymph nodes in the armpit. If cancer is detected in these lymph nodes, it is more likely to have spread to other parts of the body. In such cases, different treatment may be needed. A network of lymphatic vessels and lymph nodes ( Overview of the Lymphatic System ) drain fluid from the tissue in the breast (and other areas of the body). Lymph nodes trap foreign or abnormal cells (such as bacteria or cancer cells) that may be contained in this fluid. Thus, breast cancer cells often end up in lymph nodes near the breast, such as those in the armpit. Usually, foreign and abnormal cells are then destroyed. However, the cancer cells sometimes continue to grow in the lymph nodes or pass through the nodes into the lymphatic vessels and spread to other parts of the body. Doctors first feel the armpit to check for enlarged lymph nodes. Depending on what doctors find, they may do one or more of the following: Ultrasonographyto check for lymph nodes that may be enlarged Abiopsy(by removing a lymph node or taking a sample of tissue with a needle using ultrasonography to guide placement of the needle) Axillary lymph node dissection:Removal of many (typically 10 to 20) lymph nodes in the armpit Sentinel lymph node dissection:Removal of only the lymph node or nodes that cancer cells are most likely to spread to If doctors feel an enlarged lymph node in the armpit or are uncertain whether lymph nodes are enlarged, ultrasonography is done. If an enlarged lymph node is detected, a needle is inserted into it to remove a sample of tissue to be examined ( Testing ). Ultrasonography is used to guide placement of the needle. If the biopsy detects cancer,surgical removal of lymph nodes from the armpit (axillary lymph node dissection) may be needed. Removing many lymph nodes in the armpit, even if they contain cancer, does not help cure the cancer. However, it does help doctors decide what treatment to use. Axillary lymph nodes are evaluated again after chemotherapy is given before surgery (called neoadjuvant chemotherapy). If the biopsy after ultrasonography does not detect cancer,a sentinel lymph node biopsy is done because even if there are no cancer cells in a biopsy sample, cancer cells may be present in other parts of a lymph node. A sentinel lymph node biopsy is usually done as part of the operation to remove the cancer, such as lumpectomy or mastectomy. It enables doctors to identify and test the most important lymph node related to a breast cancer. If that lymph node is not cancerous, a woman does not need a more extensive surgery to remove all axillary lymph nodes. For asentinel lymph node biopsy,doctors inject a blue dye and/or a radioactive substance into the breast. These substances map the pathway from the breast to the first lymph node (or nodes) in the armpit. Doctors then make a small incision in the armpit and look for a lymph node that looks blue and/or gives off a radioactive signal (detected by a handheld device). This lymph node is the one that cancer cells are most likely to have spread to. This node is called a sentinel lymph node because it is the first to warn that cancer has spread. Doctors remove this node and send it to a laboratory to be checked for cancer. More than one lymph node may look blue and/or give off a radioactive signal and thus be considered a sentinel lymph node. If the sentinel lymph nodes do not contain cancer cells, no other lymph nodes are removed. If the sentinel nodes contain cancer, axillary lymph node dissection may be done, depending on various factors, such as Whether a mastectomy is planned How many sentinel nodes are present and whether the cancer has spread outside the nodes Sometimes during surgery to remove the tumor, doctors discover that the cancer has spread to the lymph nodes, and axillary lymph node dissection is required. Before the surgery is done, women may be asked whether they are willing to let the surgeon do more extensive surgery if cancer has spread to the lymph nodes. Otherwise, a second surgical procedure, if needed, is done later. Removal of lymph nodes often causes problems because it affects the drainage of fluids in tissues. As a result, fluids may accumulate, causing persistent swelling (lymphedema) of the arm or hand. After surgery, the risk of developing lymphedema continues throughout life. Arm and shoulder movement may be limited, requiring physical therapy. The more lymph nodes removed, the worse the lymphedema. Sentinel lymph node biopsy causes less lymphedema than axillary lymph node dissection. If lymphedema develops, it is treated by specially trained therapists. They teach women how to massage the area, which may help the accumulated fluid drain, and how to apply a bandage, which helps keep fluid from reaccumulating. The affected arm should be used as normally as possible, except that the unaffected arm should be used for heavy lifting. Women should exercise the affected arm daily as instructed and bandage it overnight indefinitely. If lymph nodes have been removed, women may be advised to ask health care professionals not to insert catheters or needles in veins in the affected arm and not to measure blood pressure in that arm. These procedures makes lymphedema more likely to develop or worsen. Women are also advised to wear gloves whenever they are doing work that may scratch or injure the skin of the hand and arm on the side of the surgery. Avoiding injuries and infections can help reduce the risk of developing lymphedema. Other problems that may occur after lymph nodes are removed include temporary or persistent numbness, a persistent burning sensation, and infection. A network of lymphatic vessels and lymph nodes drain fluid from the tissue in the breast. The lymph nodes are designed to trap foreign or abnormal cells (such as bacteria or cancer cells) that may be contained in this fluid. Sometimes cancer cells pass through the nodes into the lymphatic vessels and spread to other parts of the body. Although fluid from breast tissue eventually drains to many lymph nodes, the fluid usually drains first through one or only a few nearby lymph nodes. Such lymph nodes are called sentinel lymph nodes because they are the first to warn that cancer has spread. Breast reconstruction surgery may be done at the same time as a mastectomy or later. Women should consult with a plastic surgeon early during treatment to plan the breast reconstruction surgery. When reconstruction is done depends not only on the woman's preference but also on the other treatments needed. For example, if radiation therapy is done before reconstruction surgery, reconstruction options are limited. Oncoplastic breast surgery, which combines cancer (oncologic) surgery and plastic surgery, is one option. This type of surgery is designed to remove all cancer from the breast and preserve or restore the natural appearance of the breast. Most often, the surgery is done by Inserting an implant (made of silicone or saline) Reconstructing the breast using tissue taken from other parts of the woman’s body Surgeons often obtain tissue for breast reconstruction from a muscle in the lower abdomen. Alternatively, skin and fatty tissue (instead of muscle) from the lower abdomen can be used to reconstruct the breast. Before inserting an implant, doctors use a tissue expander, which resembles a balloon, to stretch the remaining chest skin and muscle to make room for the breast implant. The tissue expander is placed under the chest muscle during mastectomy. The expander has a small valve that health care professionals can access by inserting a needle through the skin. Over the next several weeks, a salt solution (saline) is periodically injected through the valve to expand the expander a little at a time. After expansion is complete, the expander is surgically removed, and the implant is inserted. Alternatively, tissues taken from the woman's body (such as muscle and tissues under the skin) can be used for reconstruction. These tissues are taken from the abdomen, back, or buttock and moved to the chest area to create the shape of a breast. The nipple and surrounding skin are usually reconstructed in a separate operation done later. Various techniques can be used. They include using tissue from the woman's body and tattooing. Surgery may also be done to modify (augment, reduce, or lift) the other breast to make both breasts match. After a general surgeon removes a breast tumor and the surrounding breast tissue (mastectomy), a plastic surgeon may reconstruct the breast. A silicone or saline implant may be used. Or in a more complex operation, tissue may be taken from other parts of the woman’s body, such as the abdomen, buttock, or back. Reconstruction may be done at the same time as the mastectomy—a choice that involves being under anesthesia for a longer time—or later—a choice that involves being under anesthesia a second time. Reconstruction of the nipple and surrounding skin is done later, often in a doctor's office. A general anesthetic is not required. In many women, a reconstructed breast looks more natural than one that has been treated with radiation therapy, especially if the tumor was large. If a silicone or saline implant is used and enough skin was left to cover it, the sensation in the skin over the implant is relatively normal. However, neither type of implant feels like breast tissue to the touch. If skin from other parts of the body is used to cover the breast, much of the sensation is lost. However, tissue from other parts of the body feels more like breast tissue than does a silicone or saline implant. Silicone occasionally leaks out of its sack. As a result, an implant can become hard, cause discomfort, and appear less attractive. Also, silicone sometimes enters the bloodstream. Some women are concerned about whether the leaking silicone causes cancer in other parts of the body or rare diseases such as systemic lupus erythematosus (lupus). There is almost no evidence suggesting that silicone leakage has these serious effects, but because it might, the use of silicone implants has decreased, especially among women who have not had breast cancer. Certain women with breast cancer have a high risk of developing breast cancer in their other breast (the one without cancer). Doctors may suggest that these women have the other breast removed before cancer develops in it. This procedure is called contralateral (opposite side) prophylactic (preventive) mastectomy. This preventive surgery may be appropriate for women with any of the following: An inherited genetic mutation that increases the risk of developing breast cancer (such as theBRCA1orBRCA2mutation) At least two close, usually first-degree relatives who have had breast or ovarian cancer Radiation therapy directed at the chest when women were under 30 years old Lobular carcinoma in situ (a noninvasive type) In women with lobular carcinoma in situ in one breast, invasive cancer is equally likely to develop in either breast. Thus, the only way to eliminate the risk of breast cancer for these women is to remove both breasts. Some women, particularly those who are at high risk of developing invasive breast cancer, choose this option. Advantages of contralateral prophylactic mastectomy include the following: Longer survival for women with breast cancer and a genetic mutation that increases risk and possibly for women who are under 50 years old when they are diagnosed with breast cancer Decreased need for cumbersome follow-up imaging tests after treatment For some women, decreased anxiety Disadvantages of this procedure include the following: Twice the risk of complications Instead of having a contralateral prophylactic mastectomy, some women may choose to have their doctor monitor the breast closely for cancer—for example with imaging tests. Radiation therapy is used to kill cancer cells at and near the site from which the tumor was removed, including nearby lymph nodes. Radiation therapy after mastectomy is done if the following are present: The tumor is 5 centimeters (about 2 inches) or larger. The cancer has spread to one or more lymph nodes. In such cases, radiation therapy after mastectomy reduces the incidence of cancer recurring on the chest wall and in nearby lymph nodes, and it improves the chances of survival. Radiation therapy after breast-conserving surgery significantly reduces the incidence of breast cancer recurring near the original tumor and in nearby lymph nodes, and it may improve overall survival. However, if women are over 70 have a lumpectomy and the cancer hasestrogenreceptors, radiation therapy may not be necessary because it does not significantly reduce the risk of recurrence or improve the chances of survival in these women. Side effects of radiation therapy include swelling in the breast, reddening and blistering of the skin in the treated area, and fatigue. These effects usually disappear within several months up to about 12 months. Fewer than 5% of women treated with radiation therapy have rib fractures that cause minor discomfort. In about 1% of women, the lungs become mildly inflamed 6 to 18 months after radiation therapy is completed. Inflammation causes a dry cough and shortness of breath during physical activity that last for up to about 6 weeks. Lymphedema may develop after radiation therapy. Chemotherapy and hormone blockers (medications that affect hormones, such astamoxifenor aromatase inhibitors) can suppress the growth of cancer cells throughout the body. To decide whether to treat with chemotherapy, doctors evaluate a few factors about a woman and the breast cancer and discuss the risks and benefits with her. Factors that doctors consider include Whether cancer has spread to lymph nodes Whether a woman is premenopausal or postmenopausal What the results of tests forestrogenreceptors andprogesteronereceptors are What the results of tests for the human epidermal growth factor 2 (HER2) oncogene are Genetic testing of the cancer (such as the Oncotype DX test) For women with invasive breast cancer, chemotherapy and/or hormone blockers are usually begun soon after surgery. These medications are continued for months or years. Some, such astamoxifen, may be continued for 5 to 10 years. If tumors are larger than 5 centimeters (about 2 inches), chemotherapy or hormone blockers may be started before surgery. These medications delay or prevent the recurrence of cancer in most women and prolong survival in some. Analyzing the genetic material of the cancer (predictive genomic testing) may help predict which cancers are susceptible to chemotherapy or hormone blockers. If women have a breast cancer withestrogenandprogesteronereceptors but no HER2 receptors and the lymph nodes are not affected, they may not need chemotherapy. Hormone blockers alone may be sufficient. Hormone blockers uses medications that interfere with the actions ofestrogenorprogesterone, which stimulate the growth of cancer cells that haveestrogenand/orprogesteronereceptors. Hormone blockers may be used when cancer cells have these receptors, sometimes instead of chemotherapy. The benefits of hormone blockers are greatest when cancer cells have bothestrogenandprogesteronereceptors and are almost as great when onlyestrogenreceptors are present. The benefit is minimal when onlyprogesteronereceptors are present. Medications used for endocrine therapy includetamoxifenand aromatase inhibitors. increases the risk of blood clots in the legs and lungs. It also increases the tendency to form polyps in the lining of the uterus (endometrial polyps), which can cause abnormal uterine bleeding, and the risk of developing Cancer of the Uterus (endometrial cancer). Thus, if a woman taking Aromatase inhibitors:These medications (anastrozole,exemestane, andletrozole) inhibit aromatase (an enzyme that converts some hormones toestrogen) and thus reduce blood levels ofestrogen. In postmenopausal women, these medications may be more effective thantamoxifen. Aromatase inhibitors may increase the risk of osteoporosis and fractures and often cause vaginal dryness. Sometimes premenopausal women are treated with a medication to suppress ovarian function (such asleuprolide) combined with an aromatase inhibitor; this is called ovarian suppression. Chemotherapy is used to kill rapidly multiplying cells or slow their multiplication. Chemotherapy alone cannot cure breast cancer. It must be used with surgery or radiation therapy. Chemotherapy is usually given intravenously in cycles. Sometimes they are given by mouth. Typically, a day of treatment is followed by 2 or more weeks of recovery. Using several chemotherapy drugs together is more effective than using a single drug. The choice of chemotherapy depends partly on whether cancer cells are detected in nearby lymph nodes. (see Chemotherapy and Other Systemic Cancer Treatments ). Side effects (such as vomiting, nausea, hair loss, and fatigue) vary depending on which chemotherapy is used. Chemotherapy can cause infertility and early menopause by destroying the eggs in the ovaries. Chemotherapy may also suppress the production of blood cells by the bone marrow and thus cause anemia or bleeding or increase the risk of infections. So drugs, such asfilgrastimorpegfilgrastim, may by used to stimulate the bone marrow to produce blood cells. Trastuzumabandpertuzumabare a type of monoclonal antibody called anti-HER2 medications. They are used with chemotherapy to treat metastatic breast cancer only when the cancer cells have too many HER2 receptors. These medications bind with HER2 receptors and thus help prevent cancer cells from multiplying. Sometimes both of these medications are used.Trastuzumabis usually taken for a year. Both medications can weaken the heart muscle. So doctors monitor heart function during treatment. (See also table Types of Breast Cancer .) Forductal carcinoma in situ,treatment usually consists of one the following: A mastectomy Removal of the tumor and a large amount of surrounding normal tissue (lumpectomy) with or without radiation therapy Women with estrogen receptor–positive orprogesteronereceptor–positive ductal carcinoma in situ may also be given hormone blockers as part of their treatment. Lobular carcinoma in situ (LCIS)is not cancer, but causes abnormal cells to form in milk glands (lobules) in the breast. People with LCIS have an increased risk of developing breast cancer. Treatment for LCIS includes the following: Classic lobular carcinoma in situ: Surgical removal to check for cancer and, if no cancer is detected, close observation afterward and sometimestamoxifen,raloxifene, or an aromatase inhibitor to reduce the risk of developing invasive cancer Pleomorphic lobular carcinoma in situ: Surgery to remove the abnormal area and sometimestamoxifenorraloxifeneto reduce the risk of developing invasive cancer Observation consists of a physical examination every 6 to 12 months for 5 years and once a year thereafter plus mammography once a year. Although invasive breast cancer may develop, the invasive cancers that develop are usually not fast growing and can usually be treated effectively. Furthermore, because invasive cancer is equally likely to develop in either breast, the only way to eliminate the risk of breast cancer for women with lobular carcinoma in situ is removal of both breasts ( Mastectomy ). Some women, particularly those who are at high risk of developing invasive breast cancer, choose this option. Women with lobular carcinoma in situ are often giventamoxifen, a hormone-blocking medication, for 5 years. It reduces but does not eliminate the risk of developing invasive cancer. Postmenopausal women may be givenraloxifeneor sometimes an aromatase inhibitor instead. For breast cancers that are within the breast and may or may not have spread to nearby lymph nodes, treatment almost always includes surgery to remove as much of the tumor as possible. One of the following may be done: Breast-conserving surgery (lumpectomy), followed by radiation therapy Mastectomy with or without breast reconstruction The initial surgery may include Lymph node assessment (removal of many lymph nodes from the armpit) or Breast-conserving surgery rather than mastectomy is used only when the tumor is not too large, because the entire tumor plus some of the surrounding normal tissue must be removed. After surgery, women may be given chemotherapy, hormone blockers, anti-HER2 medications, or a combination, depending on analysis of the tumor. There are several reasons that a woman may be treated with chemotherapy before surgery (called neoadjuvant chemotherapy). If the tumor is attached to the chest wall, chemotherapy helps make removing the tumor possible. Chemotherapy also helps shrink the size of a breast cancer that is large in relation to the rest of the breast. This increases the chances of being able to have breast-conserving surgery. Neoadjuvant chemotherapy may also be considered for treatment of breast cancers that do not have receptors for estrogen,progesterone, and HER2 (called triple negative breast cancer) and cancers that have only HER2 receptors. For breast cancers that have spread to more lymph nodes, the following may be done: Before surgery, medications, usually chemotherapy, to shrink the tumor Breast-conserving surgery or mastectomy After surgery, usually radiation therapy After surgery, chemotherapy, hormone blockers, or both Whether radiation therapy and/or chemotherapy or other medications are used after surgery depends on many factors, such as the following: How large the tumor is Whether menopause has occurred Whether the tumor has receptors for hormones How many lymph nodes contain cancer cells Breast cancer that has spread beyond the lymph nodes can not be cured, but most women who have it live at least 2 years, and a few live 10 to 20 years. Treatment response depends on the tumor biology, but may relieve symptoms and improve quality of life. However, some treatments have troublesome side effects. Thus, deciding whether to be treated and, if so, which treatment to choose can be highly personal. Choice of therapy depends on the following: Whether the cancer hasestrogenandprogesteronereceptors How long the cancer had been in remission before it spread How many organs and how many parts of the body the cancer has spread to (where the metastases are) Whether the woman is postmenopausal or still menstruating If the cancer is causing symptoms (pain or other discomfort), women are usually treated with chemotherapy or hormone blockers. Pain is usually treated with analgesics. Other medications may be given to relieve other symptoms. If curative therapy is not possible, treatments are given to reduce symptoms (called palliative therapy). Hormone blockers (endocrine therapy) is preferred to chemotherapy when the cancer has the following characteristics: The cancer isestrogenreceptor–positive. Cancer has not recurred for more than 2 years after diagnosis and initial treatment. Cancer is not immediately life threatening. Different endocrine therapies are used in different situations: Tamoxifen:Tamoxifenis often the first choice of a hormone blocker for premenopausal women. Aromatase inhibitors:For postmenopausal women withestrogenreceptor–positive breast cancer, aromatase inhibitors (such asanastrozole,letrozole, andexemestane) may be more effective as a first treatment thantamoxifen. Progestins:These medications, such asmedroxyprogesteroneormegestrol, may be used if aromatase inhibitors andtamoxifenare no longer effective. Fulvestrant:This medication may be used whentamoxifenis no longer effective. It destroys theestrogenreceptors in cancer cells. Alternatively, for premenopausal women, surgery to remove the ovaries or medications to inhibit their activity (such as buserelin,goserelin, orleuprolide) may be used to stopestrogenproduction. These therapies may be used withtamoxifenor aromatase inhibitors. Trastuzumabcan be used to treat cancers with HER2 receptors that have spread throughout the body.Trastuzumabcan be used alone or with chemotherapy (such aspaclitaxel), with hormone blockers, or withpertuzumab(another anti-HER2 medication). Tyrosine kinase inhibitors(such aslapatinibandneratinib), another type of anti-HER2 medication, block the activity of HER2. In some situations,radiation therapymay be used instead of or before medications. For example, if only one area of cancer is detected and that area is in a bone, radiation to that bone might be the only treatment used. Radiation therapy is usually the most effective treatment for cancer that has spread to bone, sometimes keeping it in check for years. It is also often the most effective treatment for cancer that has spread to the brain. Surgerymay be done to remove single tumors in other parts of the body (such as the brain) because such surgery can relieve symptoms. Mastectomy (removing the breast) may be done to help relieve symptoms. But it is unclear whether removing the breast helps prolong life when cancer has spread to other parts of the body and has been treated and controlled. Medications None Forinflammatory breast cancer,treatment usually consists of both chemotherapy and radiation therapy. Mastectomy is usually done. ForPaget disease of the breast,treatment is usually similar to that of other types of breast cancer. It often involves simple mastectomy or breast-conserving surgery plus removal of the lymph nodes. Breast-conserving surgery is usually followed by radiation therapy. Less commonly, only the nipple with some surrounding normal tissue is removed. If another breast cancer is also present, treatment is based on that type of breast cancer. Forphyllodes tumors,treatment usually consists of removing the tumor and a large amount of surrounding normal tissue (at least 1 centimeter (0.4 inch) around the tumor)—called a wide margin. If the tumor is large in relation to the breast, a simple mastectomy may be done to remove the tumor plus wide margins. Whether phyllodes tumors recur depends on how wide the tumor-free margins are and whether the phyllodes tumor is noncancerous or cancerous. Cancerous phyllodes tumors can metastasize to distant sites, such as the lungs, bone, or brain. Recommendations for treatment of metastatic phyllodes tumors are evolving, but radiation therapy and chemotherapy may be useful. Women should not become pregnant while being treated for breast cancer. If women wish to have children (preserve fertility) after being treated, they are referred to a reproductive endocrinologist before treatment is started. These women can then find out about the effect of different chemotherapy drugs on fertility and about procedures that may enable them to have children after treatment. Options to preserve fertility include Assisted Reproductive Technologies with Choice of the procedure to be used to preserve fertility depends on the following: Type of breast cancer Type of breast cancer treatment that is planned The woman's preferences Assisted reproductive techniques involve use of hormonal medications. Doctors discuss the risks and benefits of having these treatments with women who have had anestrogenorprogesteronereceptor–positive cancer. After the first phases of treatment are completed, follow-up physical examinations, including examination of the breasts, chest, neck, and armpits, are usually done every year. Regular mammograms and breast self-examinations are also important. Women should promptly report certain symptoms to their doctor: Any lumps or other changes in their breasts Changes in nipples or a discharge Pain—for example in the arm or spine Swelling in the armpit Loss of appetite or weight Chest pain Chronic dry cough Bleeding from the vagina (if not associated with menstrual periods) Severe headaches Blurred vision Dizziness or balance problems Numbness or weakness Any symptoms that seem unusual or that persist Diagnostic procedures, such as chest x-rays, blood tests, bone scans, and computed tomography (CT), are not needed unless symptoms suggest the cancer has recurred. The effects of treatment for breast cancer cause many changes in a woman’s life. Support from family members and friends can help, as can support groups. Counseling may be helpful. 