Mayo Clinic Health Decisions Guide Early Breast Cancer: What s best for me? v.10

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1 Screen # EBC_001 Section: Welcome Screen name: Welcome Screen Type: VISUAL/GRAPHICS AUDIO PROGRAMMING NOTES Graphical User Feedback Multiple choice: Please tell us why you are here? I have discovered a lump and I m looking for information about breast cancer. I was recently diagnosed with breast cancer and have to make decisions about treatment. I have already decided what treatment to have but I m interested in more information. I have a friend or family member with breast cancer. I am curious about breast cancer. (Text) A diagnosis of breast cancer is one of the most devastating experiences a woman can face. Each year more than 180,000 women receive this diagnosis and face difficult decisions about treatment. Initially, fear, shock, and anger can be so powerful as to feel disabling. You may feel isolated and overwhelmed. And nearly everyone asks the same question. Why me? We don t yet know the cause of cancer. Something apparently triggers a cell to begin dividing without control or order, threatening nearby healthy tissue. Genetic factors play a role in 5-10% of breast cancer cases. Eating a lot of fat, consistently being more than 20% over your ideal weight, and having an inactive lifestyle may put some people at higher risk. But there are no definitive answers yet. Two things are certain: 1. Your condition is NOT contagious. 2. You are NOT to blame for this disease. Primary Navigation: 1. Welcome 2. Basic Anatomy 3. About My Condition 4. Treatment Options 5. Meet the Mayo Doctor 6. Meet Other Women 7. Things to Consider Link to More About Health Decisions Images of women being comforted by family Neither are you alone. This is an important time to reach out for help. Here s why. Although the single most important factor in surviving cancer is the nature of your particular condition, some studies suggest that both your attitude and active participation in treatment decisions play key roles in your overall quality of life. And may even influence the ultimate outcome of your illness. People who maintain strong connections to family, friends, and faith seem to be at less risk than those who are more isolated. Toby A. Smith, writer page 1

2 Screen # EBC_001 Section: Welcome Screen name: Welcome Screen Type: VISUAL/GRAPHICS AUDIO PROGRAMMING NOTES (Text) Aside from family members, there is a rich network of agencies and resources to provide the information you ll need to make decisions about your health care. This web site is one of them. We ve gathered information from many sources and organized it to provide complete yet understandable information on the decisions you now face. It will take about an hour to go through all of it. Although it is NOT essential to read everything in one sitting, it IS important to review ALL the information before making a treatment decision. That way you will be fully informed and know what to expect. Images of diverse women s faces sprinkled throughout welcome area The information presented in Early Breast Cancer: What s Best for Me? is designed specifically for women with early invasive breast cancer. Please note that if you have non-invasive breast cancer or advanced breast cancer (Stage III or Stage IV) you will not find all the information you need in this section. You ll find information on treatment options for early breast cancer, including the tradeoffs involved in each treatment so you can begin to weigh the pros and cons of each choice. You can hear directly from women who ve made different treatment choices as well as hear from a practicing oncologist at the Mayo Clinic. We also offer a list of questions to ask yourself that may assist you in this very important decision making process. Links to information on other kinds of breast cancer: yo/0004/htm/abmt.htm yo/0004/htm/abmt_sb.htm Toby A. Smith, writer page 2

3 Screen # EBC_001 Section: Welcome Screen name: Welcome Screen Type: VISUAL/GRAPHICS AUDIO PROGRAMMING NOTES (text) Of course, it would be easier if all the medical information clearly pointed to a single answer. Unfortunately, there is still a lot to learn about breast cancer. Results from different medical studies sometimes provide conflicting information and medical knowledge is always increasing. The result is there is usually no one right answer. So, instead of looking for the right answer, focus on this question: What s best for me? Images of diverse women s faces sprinkled throughout welcome area Take some time. Most cancers are slow growing. Taking a few extra days up to a few weeks to carefully weigh your options is not likely to alter the outcome. On the other hand, thorough consideration of your values, lifestyle, and personal priorities will make all the difference in how happy you ultimately are with the choices you make. And even if you decide you are more comfortable asking your doctor to decide on treatment, the knowledge you will have acquired may help make the process a little less scary. Remember that, in many ways, a diagnosis of EARLY breast cancer is actually good news. Because the disease has been found early, you have more choice in treatment options and your long-term outlook is much improved. Next: Basic Anatomy Toby A. Smith, writer page 3

4 Screen # EBC_100 Section: Basic Anatomy Screen name: Basic Anatomy Screen Type: (Text) Your breast is built so you can produce milk to feed babies. Graphic build of breast: Breast alone Add label and image of lobes structure Add label and lobules structure Add label and ducts structure. Add label to areola. Add label to stroma. Each breast has between 15 and 20 sections called lobes. Each lobe is made up of many smaller structures called lobules which end in tiny bulbs that can produce milk. The lobes, lobules, and bulbs are all linked by a network of thin tubes called ducts. The ducts carry milk from the bulbs where it is produced toward the dark area of skin in the center of the breast called the areola where it becomes available to a hungry infant. The spaces around the lobules and ducts are filled with fatty tissue and ligaments referred to as stroma. The amount of fat in your breasts is largely what determines how big they are. The actual milk producing structures are nearly the same in all women. Although there are no muscles inside the breast, there are muscles underneath your breasts, separating them from your ribs. The cells that make up your breasts are fed by two separate systems of vessels. Toby A. Smith, writer page 4

5 Screen # EBC_100 Section: Basic Anatomy Screen name: Basic Anatomy Screen Type: Add label and blood vessels structure (Text) Add label and lymph vessels structure Oxygen, nutrients, and other life-sustaining nourishment are delivered to breast tissues by the blood in your arteries and capillaries. A second system of vessels carries lymph, a colorless fluid. These vessels remove lymph fluid that has been filtered by the bloodstream, draining it into lymph nodes under the arm. Lymph fluid may also carry away diseasecausing agents as well as tumor cells from the breast. Next: About My Condition Toby A. Smith, writer page 5

6 Screen # EBC_200 Section: About My Condition Screen name: About My Condition Screen Type: (text) There are many different diagnoses associated with breast cancer. The common thread is they all involve the growth of abnormal cells. The information on this web site is designed primarily for women who have received a diagnosis of early invasive (also called infiltrating) breast cancer which accounts for about 85% of all cases. About My Condition Invasive Breast Cancer DCIS LCIS Microcalcifications Stages of Cancer Grades of Cancer Ask Your Physician GRAPHIC: Non-invasive, non-infiltrating, in situ all mean the same thing. If you have received a diagnosis of or are looking for information about either non-invasive breast cancer or advanced breast cancer (Stage III or Stage IV), you will need information beyond what is available in this section. We encourage you to read through the information we have collected but please consult your physician for complete information about your treatment options. Next: Invasive Breast Cancer Toby A. Smith, writer page 6

7 Screen # EBC_201 Section: About My Condition Screen name: Invasive Breast Cancer Screen Type: (On screen Text) Carcinoma refers to abnormal cells that invade surrounding healthy tissue and can spread to other parts of the body. (text) Invasive (also called infiltrating) breast cancers (and sometimes called adeno-carcinoma) are malignant cancers which means they tend to get progressively worse, eventually threatening your life. There are two common types of invasive breast cancer. The first is invasive ductal carcinoma. This type of cancer accounts for about 70 percent of all breast cancers. About My Condition Invasive Breast Cancer DCIS LCIS Microcalcifications Stages of Cancer Grades of Cancer Ask Your Physician Animation of IDC showing abnormal patch of cells growing, breaking through duct wall into stroma. Show cells breaking off and traveling through lymph system. It begins with abnormal cell growth in a milk duct which then breaks through the duct wall, invading the breast s stroma or fatty tissue. Individual cancer cells can break off and spread or metastasize to other parts of your body through either the lymphatic system or bloodstream. Link to Anatomy Toby A. Smith, writer page 7

8 Screen # EBC_201 Section: About My Condition Screen name: Invasive Breast Cancer Screen Type: (Text) A second kind of breast cancer, invasive lobular carcinoma accounts for another percent of invasive breast cancers. Animation of ILC showing abnormal patch of cells growing, breaking through lobule into stroma. Show cells breaking off and traveling through lymph system. This cancer starts in the milk-producing lobules before spreading into the breast s stroma or fatty tissue. Like invasive ductal cancer, invasive lobular cancer can also spread to other parts of your body by way of the lymphatic system and bloodstream. Next: Ductal Carcinoma in Situ (DCIS) Toby A. Smith, writer page 8

9 Screen # EBC_202D Section: About My Condition Screen name: DCIS Screen Type: (On screen text) In situ: a Latin phrase meaning limited to one location. Graphic of DCIS (text) Not all abnormal cells infiltrate or invade surrounding tissue. You may have received a diagnosis of DCIS which stands for ductal carcinoma in situ (also called intraductal carcinoma). With DCIS, abnormal cells are confined to the lining of a milk duct and have not yet broken through the duct wall into surrounding tissue. Because cells have not spread either within the breast or to lymph nodes or other parts of your body, DCIS is technically considered non-invasive. Your doctor may also use words like pre-cancerous or premalignant. Physicians generally recommend treatment for DCIS because these cells may change over time and become invasive cancers. Next: Lobular Carcinoma in Situ (LCIS) About My Condition Invasive Breast Cancer DCIS LCIS Microcalcifications Stages of Cancer Grades of Cancer Ask Your Physician Link to anatomy Toby A. Smith, writer page 9

10 Screen # EBC_202L Section: About My Condition Screen name: LCIS Screen Type: Graphic of LCIS (text) Abnormal cells do not always infiltrate or invade surrounding tissue. You may have received a diagnosis of LCIS, an abbreviation for lobular carcinoma in situ. In LCIS, abnormal cells are confined to the lining of a milk lobule and have not yet spread to surrounding tissue, lymph nodes, or other parts of the body. LCIS is considered an indicator for increased risk of developing breast cancer. Talk with your physician about your treatment options. Next: Microcalcifications About My Condition Invasive Breast Cancer DCIS LCIS Microcalcifications Stages of Cancer Grades of Cancer Ask Your Physician Toby A. Smith, writer page 10

11 Screen # EBC_203 Section: About My Condition Screen name: Microcalcifications Screen Type: Mammography image showing microcalcifications (text) Microcalcifications are tiny deposit of calcium spotted by mammography that can appear in ducts, lobules, lymph and blood vessels, fat or skin. Most women have one or more areas of calcifications and the vast majority of these are harmless. A small percentage of calcium deposits, when seen in particular patterns, may indicate an area of rapidly dividing cells and can therefore signal the possibility of cancer. From 25 to 50% of cancers found by mammography are first noticed as clusters of microcalcifications. The remaining cancers appear as lumps. About My Condition Invasive Breast Cancer DCIS LCIS Microcalcifications Stages of Cancer Grades of Cancer Ask Your Physician Whenever calcifications appear worrisome or suspicious to the radiologist, additional mammograms and/or a biopsy may be recommended to either establish or eliminate a diagnosis of cancer. Next: Stages of Cancer For more information about microcalcifications: URL TBD: OLD URL: skphys/qa htm Toby A. Smith, writer page 11

12 Screen # EBC_204 Section: About My Condition Screen name: Stages of Cancer Screen Type: (Text) Not all breast cancers are alike. Your physician will conduct a series of tests to find out more about your specific condition. One part of this process is called staging. It's used to determine the size and location of your cancer and to see if it has spread within your breast, to your lymph nodes, or to other parts of your body. This is also a useful process for you because it provides information you will need to make intelligent treatment decisions. About My Condition Invasive Breast Cancer DCIS LCIS Microcalcifications Stages of Cancer Grades of Cancer Ask Your Physician Image of doctor examining woman It is important to remember that there are two kinds of staging. The first is clinical staging. This occurs when you first receive your diagnosis, before treatment begins. It is highly reliable. Image of technician with microscope The second type of staging, pathological staging, can only occur after surgery when actual tissue samples from your cancer can be studied under a microscope. This pathology report may not be available for up to a week after your surgery but it provides the most reliable information. Sometimes when doctors get more precise information from the pathological staging, it changes the way they previously classified a cancer. Toby A. Smith, writer page 12

13 Screen # EBC_204 Section: About My Condition Screen name: Stages of Cancer Screen Type: (Text) Doctors use Roman numerals between 0-IV to describe stages, 0 being the least threatening, IV being the most threatening. Early breast cancer involves a designation of 0, I, or II. Graphic of Stage 0 Graphic of Stage I Graphic of Stage IIA Stage 0 is very early breast cancer and has not spread either within your breast or to other parts of your body. Ductal carcinoma in situ, lobular carcinoma in situ, breast cancer in situ, and noninvasive cancer are all terms referring to Stage 0 breast cancers. Stage I refers to breast cancer that is no larger than an inch in size (less than 2 centimeters) and has not spread outside the breast. Stage II is subdivided into IIA and IIB. Stage IIA is used to define cancers that meet either of the following criteria: 1. The cancer is smaller than an inch (up to two centimeters) but has spread to the lymph nodes under the arm 2. The cancer is between 1-2 inches (2-5 centimeters) but has not spread to the lymph nodes under the arm. Graphic of Stage IIB Stage IIB applies to cancers meeting either of the following criteria: The cancer is between 1-2 inches and has spread to the lymph nodes under the arm. The cancer is larger than 2 inches (5 centimeters) but has not spread to the lymph nodes under the arm. Toby A. Smith, writer page 13

14 Screen # EBC_204 Section: About My Condition Screen name: Stages of Cancer Screen Type: Graphic of Stage IIIA (Text) Stage III breast cancers are subdivided into two classifications: In Stage IIIA, the doctor may find either: 1. A cancer smaller than two inches that has spread to the lymph nodes under the arm and to other lymph nodes beyond. 2. A cancer larger than two inches that has spread to lymph nodes under the arm. Links to information on other kinds of breast cancer: yo/0004/htm/abmt.htm yo/0004/htm/abmt_sb.htm Graphic of Stage IIIB Graphic of Stage IV In Stage IIIB cancers, the doctor may find either: A cancer that has spread to tissues near the breast (skin, chest wall, ribs or muscles in the chest). A cancer that has spread to lymph nodes inside the chest wall along the breast bone. In Stage IV, the cancer has either spread to other parts of the body (most often the lungs, liver, bones, or brain) or the tumor has spread locally to the skin and lymph nodes inside the neck, near the collarbone. Next: Grades of Cancer Toby A. Smith, writer page 14

15 Screen # EBC_205 Section: About My Condition Screen name: Grades of Cancer Screen Type: Images of four grades of cancer cells (text) In addition to categorizing your cancer by its stage, doctors will also attempt to determine its grade. The objective here is to determine the probable growth rate of the tumor and the likelihood of it spreading. Grading is done by looking at actual cancer cells under a microscope and therefore can not be done unless you ve had a biopsy or until you have surgery. Pathologists study how abnormal the cancer cells appear when compared with normal cells. Like staging, grading is also described using Roman numerals from I - IV. The higher the grade, the more aggressive the cancer and the greater the risk. Most breast cancers tend to be higher grades. Grading gives physicians important information about your prognosis and helps them figure out what treatment options to recommend. Next: Questions to Ask Your Physician About My Condition Invasive Breast Cancer DCIS LCIS Microcalcifications Stages of Cancer Grades of Cancer Ask Your Physician Toby A. Smith, writer page 15

16 Screen # EBC_206 Section: About My Condition Screen name: Questions to Ask Your Physician Screen Type: (Text) To make thoughtful treatment decisions, you will need general information as well as specific information about your own personal condition. General information is available from many agencies. The specific information is only available from your doctor. It is wise to use the time your physician can spend with you to concentrate on specific information about your case. Here are some suggested questions to ask to begin collecting the information you need. You may want to print out this list and take it with you. About My Condition Invasive Breast Cancer DCIS LCIS Microcalcifications Stages of Cancer Grades of Cancer Ask Your Physician On screen text: Hormone receptive cancers grow best in the presence of the female hormones estrogen and/or progesterone. 1. What type of cancer do I have? 2. How fast is my cancer growing? 3. How large is my cancer, where is it located, and how does that impact my treatment options? 4. How many tumors do I have and what size are they? 5. What stage and grade of cancer do I have? 6. Has the cancer spread to my lymph nodes? 7. Does my cancer have hormone receptors? 8. How does my age and whether I am pre-menopausal or post-menopausal affect my treatment options? 9. Should I get a second opinion? If you have had a biopsy, you may want to ask for an explanation of the findings of the pathology report. Link to hormone receptor information Toby A. Smith, writer page 16

17 Screen # EBC_206 Section: About My Condition Screen name: Questions to Ask Your Physician Screen Type: Image of woman and partner listening to doctor (text) Another idea is to ask your doctor for a copy of the consultation so you have a written summary of what the two of you have discussed. Consider taking someone you trust with you to each appointment so you have a second set of ears. Or ask your doctor if it s okay to tape record the consultation. Many people find it hard to take in all the information when they are also dealing with powerful emotions. Next: Treatment Options Toby A. Smith, writer page 17

18 Screen # EBC_300 Section: Treatment Options Screen name: Treatment Options Screen Type: (text) When you have invasive breast cancer, you must have some form of surgery if you plan to fight the disease. Choosing which type of surgical treatment is one of the most difficult decisions you need to make. Treatment Options: Lumpectomy and Radiation Mastectomy Breast Reconstruction Prosthetics Additional Therapies Follow up Graphic image explaining lumpectomy You have two options. Both appear to be equally effective in treating early breast cancer. In most cases, your health care providers will tell you the choice is yours. 1. You can have a lumpectomy (also called breast sparing or breast conservation surgery, abbreviated as BCS) which is always combined with radiation treatment. A lumpectomy involves removal of the cancer along with some surrounding healthy tissue to increase the likelihood of removing all the cancer cells. Radiation usually begins several weeks following surgery. Graphic image explaining mastectomy 2. You can choose mastectomy in which the entire breast is removed. In both cases, underarm lymph nodes will be removed and examined to check for the possible spread of your cancer. Link to sentinel node pop-up window #1 Toby A. Smith, writer page 18

19 Screen # EBC_300 Section: Treatment Options Screen name: Treatment Options Screen Type: Image of woman talking with doctor (Text) In some situations, a mastectomy appears to be a better choice than a lumpectomy followed by radiation: You are in the first or second trimester of pregnancy where radiation creates an unacceptable risk to your unborn child. You have two or more tumors in separate areas of the breast. You have widespread or malignant-appearing microcalcifications You have previously had radiation treatment to the breast region. There are also situations in which mastectomy may be preferable to lumpectomy: If you have a large tumor relative to the overall size of your breast, you may not have enough healthy tissue left after lumpectomy to achieve an acceptable cosmetic result. If you have a history of connective tissue disease (such as scleroderma or rheumatoid arthritis) If you have large breasts where lumpectomy might not achieve an acceptable cosmetic result or where radiation may cause significant indentation, thickening, or distortion of the tissue. If the tumor is located beneath the nipple. Next: Lumpectomy and Radiation Toby A. Smith, writer page 19

20 Screen # EBC_301A Section: Treatment Options Screen name: Lumpectomy and Radiation Screen Type: (text) Lumpectomy and Radiation When you choose a lumpectomy, you are choosing a two stage process. The first stage is the surgery to remove the cancer and axillary (under the arm) lymph nodes. The second stage is radiation treatment. A lumpectomy without radiation is not currently recommended because the tendency for cancer to recur is higher. Next: Lumpectomy: Phase One/The Surgery Treatment Options: Lumpectomy and Radiation The Surgery Radiation Tradeoffs Mastectomy Breast Reconstruction Prosthetics Additional Therapies Follow up Toby A. Smith, writer page 20

21 Screen # EBC_301A Section: Treatment Options Screen name: Lumpectomy and Radiation-The Surgery Screen Type: Animation showing surgical lumpectomy Lumpectomy: Phase One/The Surgery Breast sparing surgery usually takes less than two hours and requires a hospital stay of 1-3 days. Sometimes it is done as outpatient surgery. In the operating room, your surgeon makes an incision in the breast large enough to allow for the removal of both the tumor and a margin of healthy tissue surrounding the cancer. This size of the margin is approximately one centimeter or less than half an inch. The margin is taken to help ensure that all the cancer cells are removed. The surgeon will make a second incision under the arm to remove lymph nodes. These nodes, along with the tissue samples from your cancer, will be examined under a microscope to see whether the disease may have spread to other parts of your body. This information is extremely important in figuring out what additional treatments, if any, will be recommended. Treatment Options: Lumpectomy and Radiation The Surgery Radiation Tradeoffs Mastectomy Breast Reconstruction Prosthetics Additional Therapies Follow up Toby A. Smith, writer page 21

22 Screen # EBC_301A Section: Treatment Options Screen name: Lumpectomy and Radiation-The Surgery Screen Type: (text) Removal of lymph nodes is very individualized. Some are more easily removed. In some women, they are more deeply embedded in nerves and muscles. The number of lymph nodes removed depends on the location of your cancer, your individual body anatomy, and the surgical procedure itself. Some doctors will use a technique during surgery to identify the sentinel node as a way to determine how many lymph nodes should be removed. Ask your surgeon whether he or she will attempt to identify the sentinel node as part of your surgery. Click here for more information about identifying the sentinel node. Link to Sentinel Node Window #1 Graphic showing location of lymph nodes Doctors pay close attention to the number and location of nodes that contain cancer cells as well as the amount of cancer they contain. This information offers an indication of how likely it is that cancer has spread to other parts of your body. If cancer cells are found in 1-3 nodes (also called positive nodes), that is more encouraging. Cancer cells detected in more than three nodes means a greater likelihood that cancer may have already spread. In this situation, doctors would likely recommend additional or adjuvant treatments like hormonal therapy or chemotherapy. Toby A. Smith, writer page 22

23 Screen # EBC_301A-Window Section: Treatment Options Screen name: Window #1-Sentinel Node Screen Type: Animation of Sentinel node location Identifying the Sentinel Node In many hospitals, doctors first inject a harmless dye into the breast to identify what they call the sentinel node. This is the first node the dye reaches as it begins to travel away from the breast and is therefore considered representative of the other nodes. The thinking goes like this: if the sentinel node is the first node the dye reaches, it s likely the first node the cancer would spread to. This opens a pop up window with this information about sentinel nodes and animation Technician with microscope Once the sentinel node is identified it is removed and examined under a microscope. If no cancer cells are present, the likelihood is that other lymph nodes are also clean. The benefit of identifying the sentinel node is that it limits the total number of lymph nodes which have to be removed along with the potential associated side effects of lymphedema. End of pop up window Toby A. Smith, writer page 23

24 Screen # EBC_301A Section: Treatment Options Screen name: Lumpectomy and Radiation-The Surgery Screen Type: Graphic of drain (text) After the surgeon completes the node removal, a rubber drain the thickness of a thin drinking straw is gently sewn into place to draw off fluids and keep swelling down. The end is attached to a suction device similar to the kind used to irrigate ears. You will be instructed in how to monitor the amount of drainage and care for this drain until it is removed about 10 days after your surgery. Some women find this aspect of surgery bothersome but it should not be painful. Excessive pain after lumpectomy is usually not a major factor. Most women experience more discomfort from the lymph node removal than from the tumor removal. You may experience a feeling of tightness or numbness, particularly under the arm. Some of this numbness gradually fades as nerve cells regenerate. Some women, however, experience numbness the rest of their lives, though this is not dangerous. Toby A. Smith, writer page 24

25 Screen # EBC_301A Section: Treatment Options Screen name: Lumpectomy and Radiation-The Surgery Screen Type: Post surgical patient resting (text) Fatigue is to be expected following the surgery. In addition to the emotionally draining experience of facing cancer surgery, it is physically taxing as well. It s a good idea to plan a lighter schedule, with the possibility of daily naps, for the weeks following your surgery. Next: Lumpectomy: Phase Two/Radiation Toby A. Smith, writer page 25

26 Screen # EBC_301B Section: Treatment Options Screen name: Lumpectomy and Radiation-Radiation Screen Type: image of radioactive tubes image of woman with radiation machine (text) Lumpectomy: Phase Two/Radiation After you have had several weeks to heal from your surgery, you will begin the second stage of your treatment radiation. Radiation is administered in two ways: from an x-ray machine or from tiny tubes of radioactive material implanted in your breast. Both treatments are equally effective but the implantation method is much less common. It requires minor surgery and a brief hospital stay and involves some isolation in order to protect others from exposure to the radiation. Radiation administered from a machine is much more common. The customary schedule for radiation treatments is every weekday for six weeks. Occasionally a booster treatment of an additional five visits is also recommended at the end. Each treatment is painless and takes just a few minutes. In many treatment centers, you can set up an appointment at the same time each day so the treatment becomes part of your daily routine. Treatment Options: Lumpectomy and Radiation The Surgery Radiation Tradeoffs Mastectomy Breast Reconstruction Prosthetics Additional Therapies Follow up Toby A. Smith, writer page 26

27 Screen # EBC_301B Section: Treatment Options Screen name: Lumpectomy and Radiation-Radiation Screen Type: Image of tattoo marks Image of permanent marker being used (text) Before you start treatment, the radiation oncologist carefully maps your breast so that the machine will be able to deliver radiation to the precise location of your cancer. This mapping takes about an hour. It involves placing ink marks on your skin to provide a reference point for the technician who administers the radiation. Sometimes these marks take the form of small permanent tattoos which look like freckles. Marks may be made with a permanent marker instead of a tattoo. But even permanent ink can wash or wear off over time and if the marks can not be clearly seen, you will have to repeat the mapping process at one or more points during your treatment. Radiation is a cumulative process and its side effects tend to become more of an issue as time passes. Fatigue is the most common complaint. It s a good idea to plan for this possibility so that you can rest whenever you feel the need. Sometimes putting your feet up for minutes is enough. Image of breast suffering skin irritation Other side effects include skin irritation, including itchiness, redness, shininess, soreness, peeling, blistering, swelling, and decreased or hyper sensation. Many of these symptoms may feel similar to those you ve experienced with a sunburn. These symptoms go away after treatment ends. Toby A. Smith, writer page 27

28 Screen # EBC_301B Section: Treatment Options Screen name: Lumpectomy and Radiation-Radiation Screen Type: (text) A small percentage of women experience more serious problems like swelling in the arm, broken ribs, or lung problems. Image of breast showing permanent change Some changes to the breast may be permanent after radiation. These include changes in skin color, feelings of heaviness in the breast, changes in the texture of the breast, even size changes. Next: Lumpectomy Tradeoffs Toby A. Smith, writer page 28

29 Screen # EBC_301C Section: Treatment Options Screen name: Lumpectomy and Radiation-Tradeoffs Screen Type: Graphic chart summarizing tradeoffs of lumpectomy with radiation (Text) Lumpectomy: Pros The primary advantage of lumpectomy is that it conserves your breast. Many women find that after healing their breasts have a near normal appearance. And for many, this is of great psychological value. Lumpectomy: Cons Cancer can recur. The long term prognosis for recurrence of cancer in women choosing lumpectomy with radiation versus mastectomy is virtually the same. However women choosing a lumpectomy and radiation do have a slightly greater chance of developing a cancer caused by the radiation itself. This risk depends on two factors: first, the amount of radiation and second, the age at the time of exposure. The younger the woman and the higher the dose, the greater the risk. With increasing age, the risk declines. For women over the age of 40 years, the risk seems to be negligible. Treatment Options: Lumpectomy and Radiation The Surgery Radiation Tradeoffs Mastectomy Breast Reconstruction Prosthetics Additional Therapies Follow up Two less successful post surgical lumpectomy pictures Lumpectomy with radiation may produce unsatisfactory cosmetic results in women with large tumors because a larger volume of the breast must be removed. Toby A. Smith, writer page 29

30 Screen # EBC_301C Section: Treatment Options Screen name: Lumpectomy and Radiation-Tradeoffs Screen Type: (text) The regularity of radiation treatments may be inconvenient for some women, particularly those who live far from the treatment center. Some women find the side effects of radiation bothersome. For the first weeks or months following radiation treatment, when there is swelling and fluid accumulation, mammography may be somewhat less reliable in detecting breast cancers. Once the breast heals, mammograms become more reliable again. Another potential side effect of breast cancer treatment is lymphedema, an abnormal build up of fluid in the limb or breast and chest wall. The exact reason for development of lymphedema is not clear, but may be related to the surgery with removal of lymph nodes, or irritation from radiation to the area. This complication does not occur often but can develop soon after treatment or many years later. When lymphedema does occur, prompt treatment is important. Though not life threatening, lymphedema can limit arm and hand function, be uncomfortable, and also increase risk for local infection in the limb. Link to Basic Anatomy Link to Window #2 on Lymphedema Click here for more information about Lymphedema. Next: Mastectomy Toby A. Smith, writer page 30

31 Screen # EBC_301C-Window #2 Section: Treatment Options Screen name: Window #2-Lymphedema Screen Type: Image of lymphedema patient More About Lymphedema If you develop lymphedema, you should ask to see an edema therapist, often a physical or occupational therapist who has received special training. There are many treatment options available to help reduce the swelling. Special exercises are part of any lymphedema program. Often a pressure sleeve is used, but it works best after the fluid is reduced, because its job is to keep fluid from returning. A pop up window with this information about lymphedema and graphic images Image of woman having blood pressure taken or shot administered Image of woman gardening with gloves Fortunately, there are some simple measures you can take to reduce the risk of lymphedema. Nearly all fall under the general recommendation to take special care with that arm. Carry heavy packages and handbags with the other arm. Avoid sunburns, burns, or cuts to the affected arm. Have blood drawn, shots administered, and blood pressure taken on the other arm. Wear gloves when gardening or using skin irritants. Use long oven mitts when baking Avoid temperature extremes such as hot tubs, hot soaks, and hot dishwater. Think before over-using your arm in activities like raking, wallpapering, and heavy cleaning Keep you hands and arms well lubricated. Avoid tight jewelry or clothing (like elastic cuffs). Take care in manicuring your fingers to avoid injury. When a cut or other injury occurs, treat it promptly and apply anti-bacterial medication. Continue your exercises as instructed by your health care provider. Don t forget to wear your sleeve, especially when it Toby A. Smith, writer page 31

32 is hot and humid. When a cut or injury occurs, consult your doctor immediately if you see any signs of infection (redness of the arm). End of the pop up window Toby A. Smith, writer page 32

33 Screen # EBC_302 Section: Treatment Options Screen name: Mastectomy Screen Type: Animation of modified radical mastectomy (text) Mastectomy: Introduction Mastectomy is a term used for several different procedures: A modified radical mastectomy is the most common procedure used to treat invasive breast cancer. It involves removing the entire breast, including the skin, areola, and nipple, as well as most of the lymph nodes under the arm. Treatment Options: Lumpectomy and Radiation Mastectomy The Surgery Tradeoffs Breast Reconstruction Prosthetics Additional Therapies Follow up Graphic of radical mastectomy In contrast, a radical mastectomy removes the breast, chest muscles, all the lymph nodes under the arm, and some additional fat and skin. For many years this was the standard treatment for women with breast cancer. Today it is used only in cases of advanced cancer which has already spread to chest muscles. Toby A. Smith, writer page 33

34 Screen # EBC_302 Section: Treatment Options Screen name: Treatment Options-Mastectomy Screen Type: (text) Another procedure you may have heard about is prophylactic mastectomy, the removal of most normal breast tissue before the development of cancer in women at high risk for breast cancer. When there is a significant family history of the disease (a mother, sisters, and/or daughters already diagnosed), some women may elect to have this procedure. Links about prophylactic mastectomy: line/htm/hw htm /htm/breastop.htm The advantage is that this procedure significantly reduces the risk of developing breast cancer. However, if a woman chooses to have surgical breast reconstruction, it is a major procedure and there are lasting effects on body appearance. Gene testing to identify those who have an abnormal breast cancer gene ( BRCA1 and BRCA2) associated with inherited breast cancer is now available. If there is a strong history of breast cancer in your family (and/or a history of other cancers like ovarian, colon, or prostate), you may want to talk with your physician about a referral to a genetic counselor to discuss gene testing. Remember that having a family history does not necessarily mean you have inherited a defective gene. And 85% of breast cancers occur in women with no prior family history. Link for more information about gene testing; /htm/brca.htm TBA: a second Mayo link on sisters making different choices about gene testing. Next: Mastectomy The Surgery Toby A. Smith, writer page 34

35 Screen # EBC_302A Section: Treatment Options Screen name: Mastectomy-The Surgery Screen Type: (text) Modified Radical Mastectomy: The Surgery The treatment information in this section focuses on the modified radical mastectomy since that is the most common type of mastectomy performed. This type of surgery, without reconstruction, takes 1-4 hours and usually involves a 2-5 day hospital stay. Treatment Options: Lumpectomy and Radiation Mastectomy The Surgery Tradeoffs Breast Reconstruction Prosthetics Additional Therapies Follow up Animation of Modified radical mastectomy A single incision across half the chest usually allows the surgeon to remove both the breast and lymph nodes. Some doctors will use a technique to identify the sentinel node during surgery as a way to determine how many lymph nodes should be removed. Ask your surgeon whether he or she will attempt to identify the sentinel node as part of your surgery. Click here for more information about identifying the sentinel node. Link to Window #1 on Identifying the sentinel node The lymph nodes and tissue samples from your cancer are examined under a microscope to see whether the disease may have spread to other parts of your body. This information is extremely important in figuring out what additional treatments, if any, will be recommended. Toby A. Smith, writer page 35

36 Screen # EBC_302A Section: Treatment Options Screen name: Mastectomy-The Surgery Screen Type: Graphic of drain (text) After the surgeon completes the node removal a rubber drain about the width of a thin drinking straw is gently sewn into place to draw off fluids and help keep swelling down. The end of the drain is attached to a suction device like the kind used to irrigate ears. You will be instructed in the care of this drain and how to monitor the drainage until it is removed about 10 days after your surgery. Although some women find this bothersome it should not be painful. Most women with breast cancer do not experience excessive pain following mastectomy. More complain about a sensation of numbness under the arm. This occurs because nerves are often cut as part of the lymph node removal. Some of this numbness slowly fades as nerve cells regenerate. Some numbness and swelling of the arm may be permanent. Toby A. Smith, writer page 36

37 Screen # EBC_302A Section: Treatment Options Screen name: Mastectomy-The Surgery Screen Type: In most cases of early breast cancer, radiation treatment is not indicated after mastectomy. However, radiation may be recommended if: your tumor is larger than two inches (5 cm) and you have positive lymph nodes cancer cells are found in many lymph nodes, or your tumor is close to the rib case or chest wall muscles which increases the likelihood that cancer cells may have spread to other parts of your body. Next: Mastectomy--Tradeoffs Toby A. Smith, writer page 37

38 Screen # EBC_302B Section: Treatment Options Screen name: Mastectomy-Tradeoffs Screen Type: (text) Mastectomy: Pros The primary advantage of choosing a mastectomy over a lumpectomy is that mastectomy is a one step cancer treatment. Once you heal from the surgery, you will need to be closely monitored. But while some women may consider additional treatment options, in most cases, these are not required. Treatment Options: Lumpectomy and Radiation Mastectomy The Surgery Tradeoffs Breast Reconstruction Prosthetics Additional Therapies Follow up Graphic chart summarizing tradeoffs of mastectomy Mastectomy: Cons Even though the breast is gone, cancer can still recur in the scar or chest wall. Although there is somewhat less risk of recurrence following a mastectomy when compared with lumpectomy, there are no guarantees. Because a mastectomy removes the entire breast, it may involve a grieving process. You lose a part of your body. And the surgery leaves a daily physical reminder of your disease. This can be difficult. Sometimes the absence of the breast raises issues around sexual self-image though usually these pass with time and support from your loved ones. Toby A. Smith, writer page 38

39 Screen # EBC_302B Section: Treatment Options Screen name: Mastectomy-Tradeoffs Screen Type: (text) Some women, particularly those with large breasts, experience a feeling of being lopsided. Most get accustomed to the feeling over time. For others, the issue may be resolved by breast reconstruction. Others experience tenderness around the scar or permanent numbness under the arm. Another potential side effect of mastectomy is lymphedema, a buildup of fluid in the arm next to the removed breast. Lymphedema is related to the removal of lymph nodes. Click here for more information about Lymphedema. Next: Breast Reconstruction Link to Window #2 on Lymphedema Toby A. Smith, writer page 39

40 Screen # EBC_303 Section: Treatment Options Screen name: Breast Reconstruction Screen Type: (text) While you are gathering information to determine treatment options, you will no doubt want to consider how to deal with your appearance after mastectomy. There are several techniques and choices to explore: 1. Breast reconstruction with tissue expanders 2. Breast reconstruction with implants 3. Breast reconstruction with flaps 4. Prosthesis (external artificial breast) 5. Do nothing. Breast reconstruction is a surgical procedure designed to restore a more naturally shaped breast after mastectomy. It is complicated surgery and can be more painful and require a longer recovery than the initial cancer surgery. At the same time, some women find this surgery easier to tolerate than a mastectomy because they perceive it leading toward something they want. Perhaps the most important thing to understand about reconstruction is that it does not restore the normal breast sensation you are accustomed to. Consider the information presented on reconstruction here as an overview only. You will want to gather more information from a plastic surgeon before making a decision. Treatment Options: Lumpectomy and Radiation Mastectomy Breast Reconstruction Tissue Expanders Implants Flaps Prosthetics Additional Therapies Follow up Toby A. Smith, writer page 40

41 Screen # EBC_303 Section: Treatment Options Screen name: Breast Reconstruction Screen Type: Images of women with reconstructed breasts, showing variety in race, size, results (text) Reconstruction is sometimes done at the same time as a mastectomy but it can also be done months or even years later. Some plastic surgeons believe the results are better when a patient has healed thoroughly from the mastectomy before beginning reconstruction. But for some women, waking up from a mastectomy with a reconstructed breast is very important. One consideration in combining reconstruction with mastectomy is that reconstruction can interfere in some kinds of chemotherapy treatments. If you are a candidate for chemotherapy, you may want to delay reconstruction. Reconstruction may require multiple surgical procedures. For example, if you decide you want to add a nipple or if you choose to alter the shape or size so the reconstructed breast more closely matches the natural breast. Next: Breast Reconstruction Tissue Expanders Toby A. Smith, writer page 41

42 Screen # EBC_303A Section: Treatment Options Screen name: Breast Reconstruction: Tissue Expander Screen Type: Image of tissue expander add Simulation label In tissue expansion, a balloon in surgically placed under the chest muscle with a small valve that remains outside the skin. During a series of weekly office visits over the next 2-3 months, this balloon is gradually filled with saline (salt water) by injections into the valve. The filling is done gradually to give the skin covering the balloon a chance to stretch between visits. When the tissue expansion is complete, the temporary expander is replaced with a permanent implant. Tissue expansion is often used in women with larger breasts where an implant alone is not able to match the size of the normal breast. Next: Breast Reconstruction Implants Treatment Options: Lumpectomy and Radiation Mastectomy Breast Reconstruction Tissue Expanders Implants Flaps Prosthetics Additional Therapies Follow up Toby A. Smith, writer page 42

43 Screen # EBC_303B Section: Treatment Options Screen name: Breast Reconstruction-Implants Screen Type: Image of saline filled implant and silicone gel implant (text) An implant is a breast shaped device that is secured inside your body, held in place by your chest muscles. It is the technique most often performed in smaller breasted women. There are two kinds of implants. Implants filled with saline are the ones commonly used now. Use of implants filled with silicone gel have been limited by the Food and Drug Administration because of reports those implants have caused health problems. An implant requires additional surgery unless you elect to have it put in at the time of the mastectomy. It also requires a series of doctor visits after surgery. Implants may cause pain, swelling, bruising, tenderness or infection. And they do age over time requiring replacement. There is also a long-term possibility of rupture, deflation, and shifting. Next: Breast Reconstruction Flaps Treatment Options: Lumpectomy and Radiation Mastectomy Breast Reconstruction Tissue Expanders Implants Flaps Prosthetics Additional Therapies Follow up Toby A. Smith, writer page 43

44 Screen # EBC_303C Section: Treatment Options Screen name: Breast Reconstruction-Flaps Screen Type: Animation showing three sources of flap, then showing tunneling from abdomen to breast location (text) The most complex reconstruction procedure with the longest recovery time is a flap. During this surgery, a section of tissue taken from one part of your body (usually the back or abdomen, sometimes the buttocks) is used to fashion a new breast. It requires multiple incisions and the surgical wounds can be large. The flap, along with its blood supply, is usually moved to its new location by tunneling it under the skin. An advantage is that this breast is made from your own body tissue. At the same time, because it is human tissue, it requires adequate blood supply. If blood supply to the flap is poor, the transplant may not survive. Next: Prosthetics Treatment Options: Lumpectomy and Radiation Mastectomy Breast Reconstruction Tissue Expanders Implants Flaps Prosthetics Additional Therapies Follow up Toby A. Smith, writer page 44

45 Screen # EBC_304 Section: Treatment Options Screen name: Prosthetics Screen Type: (text) Instead of reconstruction, you may decide a prosthesis is a better solution. A prosthesis is shaped like a breast but remains outside your body. They are usually made from nylon, rubber, silicone, or Dacron fiberfill and slip into your bra. Treatment Options: Lumpectomy and Radiation Mastectomy Breast Reconstruction Prosthetics Additional Therapies Follow up Images of prosthetics, different shapes and sizes There are a range of generic shapes and sizes available to use temporarily immediately following your surgery. But you will also receive information on getting a more customized, permanent prosthesis for long-term use. Check carefully with your insurance company to see what kind of coverage you have. Sometimes a prosthesis prescription from your doctor helps with insurance coverage. Some companies cover either prosthesis or reconstruction but not both. Your final option after mastectomy is to do nothing. No reconstruction and no prosthesis. Many women are content with this choice. Next: Additional Therapies Toby A. Smith, writer page 45