Making a Decision About Treatment

The only way to find out for sure if a breast lump or abnormal tissue is cancer is by having a biopsy. The suspicious tissue that is removed by a surgeon or radiologist during a biopsy is examined under a microscope by a pathologist who makes the diagnosis. If your biopsy result is positive, it means that the tumor or tissue from the suspicious area contains cancer and you will need treatment. Information on the following pages can help you understand the various treatments that are available and decide what is best for you. It is safe to begin treatment up to several weeks after diagnosis. This gives you time to:

* Have a complete study of your breast tissue and tests of other parts of your body.
* Get other opinions about your diagnosis and the suggested treatment plan.
* Talk with each of the specialists who will be on your treatment team.
* Call your health insurance plan before treatment begins.
* Call NCI's Cancer Information Service at 1-800-4-CANCER for the most up-to-date, accurate breast cancer treatment information.
* Contact breast cancer organizations to find support groups near you.
* Talk with other women who have had breast cancer and have gone through treatment.
* Prepare yourself and loved ones for your treatment.

Remember, you don't have to face breast cancer alone - there are knowledgeable and caring people who can help you.

Are All Breast Cancers Alike?

Breast cancer is a complex disease. All cases are not the same. Once breast cancer has been found, more tests will be done to find out the specific pattern (description) of your disease. This important step is called staging. The following chart explains the stages. Knowing the exact stage of your disease will help your doctor plan your treatment. Your doctor will want to know:

* The size of the tumor and exactly where it is in your breast.
* If the cancer has spread within your breast.
* If cancer is present in your lymph nodes under your arm.
* If cancer is present in other parts of your body.

Staging - Specific Patterns of Breast Cancer

Stage 0

Very early breast cancer. This type of cancer has not spread within or outside the breast. It is sometimes called DCIS, LCIS, or breast cancerin situ or noninvasive cancer.

Stage I

The cancer is no larger than about 1 inch in size and has not spread outside the breast. (Also described as early breast cancer.)

Stage II

The doctor may find any of the following:
* The cancer is no larger than 1 inch, but has spread to the lymph nodes under the arm.
* The cancer is between 1 and 2 inches. It may or may not have spread to the lymph nodes under the arm.
* The cancer is larger than 2 inches, but has not spread to the lymph nodes under the arm.

Stage III

Stage III is divided into stages IIIA and IIIB:

The doctor may find either of the following:

* The cancer is smaller than 2 inches and has spread to the lymph nodes under the arm. The cancer also is spreading further to other lymph nodes.
* The cancer is larger than 2 inches and has spread to the lymph nodes under the arm.

Stage IIIB

The doctor may find either of the following:

* The cancer has spread to tissues near the breast (skin, chest wall, including the ribs and the muscles in the chest).
* The cancer has spread to lymph nodes inside the chest wall along the breast bone.

Stage IV

The cancer has spread to other parts of the body, most often the bones, lungs, liver, or brain. Or, the tumor has spread locally to the skin and lymph nodes inside the neck, near the collarbone.

Inflammatory Breast Cancer

Inflammatory breast cancer is a rare, but very serious, aggressive type of breast cancer. The breast may look red and feel warm. You may see ridges, welts, or hives on your breast; or the skin may look wrinkled. It is sometimes misdiagnosed as a simple infection.

Recurrent Breast Cancer

Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the breast, in the soft tissues of the chest (the chest wall), or in another part of the body.
(Tumor size is usually reported in metric measurement: 1 centimeter = approximately 1/2 inch.)

Breast Cancer in situ - DCIS and LCIS

Many breast cancers being found are very early cancers known as breast cancer in situ or noninvasive cancer. Most of these cancers are found by mammography. These very early cell changes may become invasive breast cancer. Two types of breast cancer in situ are:

DCIS (ductal carcinoma in situ), which means that abnormal cells are found only in the lining of a milk duct of the breast. These abnormal cells have not spread outside the duct. They have not spread within the breast, beyond the breast, to the lymph nodes under the arm, or to other parts of the body. There are several types of DCIS. If not removed, some types may change over time and become invasive cancers. Some may never become invasive cancers. (DCIS is sometimes called intraductal carcinoma.)

LCIS (lobular carcinoma in situ), which means that abnormal cells are found in the lining of a milk lobule. Although LCIS is not considered to be actual breast cancer at this noninvasive stage, it is a warning sign of increased risk of developing invasive cancer. LCIS is sometimes found when a biopsy is done for another lump or unusual change that is found on a mammogram. Patients with LCIS have a 25 percent chance of developing breast cancer in either breast during the next 25 years.

Microcalcifications are very small specks of calcium that can't be felt, but can be seen on a mammogram . They are formed by rapidly dividing cells. When they are clustered in one area of the breast, this could be an early sign of breast cancer in situ. About half of the breast cancers found by mammography appear as clusters of microcalcifications. The other half appear as lumps.

To be sure that you have a correct diagnosis if breast cancer in situ is detected, an experienced pathologist should examine your biopsy slides. You may want to have yourslides examined also by a second pathologist at a university hospital, cancer center, or breast clinic. This is important because it is sometimes difficult to make an accurate diagnosis. The pathologist needs to determine the types of cells that are present in the tissue sample, how fast the cells are changing, and whether it is likely to become invasive cancer. The diagnosis will help your doctor decide on the appropriate treatment from a wide range of choices. The decision could be to have frequent followup exams to watch the suspicious area, or surgery to remove only the affected tissue, or surgery to remove one or both breasts. Surgery removing only the affected area is sometimes followed by radiation therapy to the breast.

Prognosis (Chance of Recovery)

Most women who are treated for early breast cancer go on to live healthy, active lives. You may have more choices of treatment if your breast cancer is found early.

Treatments have changed over time. Today, many women who are diagnosed with breast cancer do not have to lose a breast. Because there are improved ways to treat breast cancer, it is more important than ever for you to learn all you can. Working with your team of medical specialists, you can play a key role in choosing the treatment that is best for you.

Once your doctor has determined your specific type and stage of breast cancer, you can begin to plan for your treatment and recovery. Your chance of recovery will depend on many factors, including:

* The type and stage of your cancer (what kind of cancer; the size of the tumor; and whether it is only in your breast, or has spread to any lymph nodes or to other parts of your body).
* How fast the cancer is growing. Special lab tests on the tissue can measure how fast the cancer cells are dividing and how different they are compared to normal breast cells.
* How much the breast cancer cells depend on female hormones (estrogen and progesterone) for growth which can be measured by hormone receptor tests. Patients whose tumors are found to be dependent on hormones (described as estrogen-positive or progesterone-positive) can be treated by hormonal therapy to prevent further growth or recurrence of breast cancer. (See section on hormonal therapy.)
* Your age and menopausal status (whether or not you still have monthly menstrual periods).
* Your general state of health.

Risk Factors for Recurrence

Your chance of surviving breast cancer will also depend upon your risk for return of cancer after treatment is completed. Some women are at higher risk for the spread or return of breast cancer. In many cases, doctors can't explain why one patient stays well and another does not. Remember, the risk factors for recurrence are complex. They are not absolute predictions of your future health. Some factors that affect the spread or the recurrence of breast cancer are:

* Tumor size: The smaller your tumor, the lower the risk.
* Lymph nodes: The fewer underarm lymph nodes that have cancer, the lower your risk.
* Cell growth: Cancer cells that grow slowly are linked to a lower risk.
* Hormones: If a tumor depends on hormones for growth, hormonal therapy can lower the risk of cancer spread or recurrence.

QUESTIONS TO ASK YOUR DOCTOR AFTER A BIOPSY

Please explain what is on the pathology report. 

What type of breast cancer do I have?

What stage of breast cancer do I have? 

Did a pathologist who is experienced in diagnosing breast cancer examine my biopsy slides? 

Should my biopsy slides be examined again? Why or why not?

What are the chances that the cancer has spread within or outside my breast? 

Were lab tests done on the tumor tissue? What do the results mean for me? 

Were estrogen and progesterone receptor tests done? What do the results mean for me? (See section on hormonal therapy.) 

What other tests do I need? (Chest x-ray, bone scan, etc.) 

What are my treatment choices? 

How can I get more information about them? 

What benefit can I expect from each kind of treatment? 

What are the risks and possible side effects of each treatment? Short-term? Long-term? 

What are the risks if I don't get treatment? 

What are my chances for recurrence? 

How can I get another opinion? 

Is there any research being done on my kind of cancer? 

Your Treatment Team

Once your doctor has all the specific information about your breast cancer, you will talk about all the treatments considered appropriate for your case. No one doctor is able to provide all the care and services you may need, and you will quickly learn about new people who will be on your treatment team. Some of the medical experts who may be part of your treatment team are:

Anesthesiologist: a doctor who gives drugs or gases that keep you comfortable during surgery.

Gynecologist: A doctor who specializes in the care and treatment of women's reproductive systems. This doctor or your primary care doctor can serve as the manager and main source of information among your treatment team members and you.

Nutritionist or dietitian: a health professional with specialized training in nutrition who can offer help and choices about the foods you eat.

Oncologist, medical oncologist, or cancer specialist: a doctor who uses chemotherapy or hormonal therapy to treat cancer. This specialist can put together all the information about your case and can discuss your treatment choices with you.

Oncology nurse: a nurse with special training in caring for cancer patients. You may also receive care from a clinical nurse specialist or nurse practitioner.

Oncology pharmacy specialist: a person who prepares anticancer drugs in consultation with the oncologist and can answer your questions about chemotherapy.

Pathologist: a doctor who examines tissues and cells under a microscope to determine if they are normal or abnormal.

Physical therapist: a health professional who teaches exercises that help restore arm and shoulder movement and build back strength after breast cancer surgery.

Plastic surgeon or reconstructive surgeon: a doctor who can surgically rebuild (reconstruct) your breast.

Primary care doctor: the doctor who usually manages your health care and can discuss cancer treatment choices with you.

Psychologist: a specialist who can talk with you and your family about emotional and personal matters, and can help you make decisions.

Radiation oncologist: a doctor who uses radiation therapy to treat cancer.

Radiation therapist: a health professional who gives radiation treatments.

Radiologist: a doctor with special training in reading x-rays and performing specialized x-ray procedures.

Social worker: a professional who can talk with you and your family about your emotional or physical needs and can help you find support services. An oncology social worker has specific training in working with cancer patients.

Surgeon or surgical oncologist: a doctor who performs biopsies and other surgical procedures such as removing a lump (lumpectomy) or a breast (mastectomy).

A SECOND OPINION

Once you receive your doctor's opinion about what treatments you need, you have the right to get more advice before you make up your mind. Other doctors' opinions can help you make one of the most important decisions of your life. Getting another doctor's advice is normal medical practice, and your doctor can help you with this effort. Many health insurance companies require and will pay for other opinions. Another opinion can help you:

* Confirm or adjust your treatment plan based on the diagnosis and stage of the disease.
* Get answers to your questions and concerns and help you become comfortable with your decisions.
* Decide about taking part in a research study of new breast cancer treatment methods. (See Clinical Trials)

To get a second opinion:

* Ask your doctor to refer you to another breast cancer specialist who is not already on your treatment team. Take along your mammogram films, biopsy slides, pathology report, and proposed treatment plan when you see this doctor.
* Call the NCI's Cancer Information Service for help in locating cancer centers that may be in your area.
* Talk with women in breast cancer organizations, cancer survivor groups, or other women who have been through breast cancer treatment. Keep in mind, however, that all breast cancer cases are not the same. Individual experiences and treatments may be different.