Breast Cancer

What you can expect after the mammogram:

1) The radiologist may explain your results at the time of mammogram/

ultrasound (If this is not offered, you can request it, but often you may

need to schedule a consultation.)

2) The detailed report of the findings is usually sent directly to your primary

or referring physician. If you want it, you may have a copy of this report.

Ask the doctor who received it.

3) You will also receive a brief report by mail of the radiologist’s findings

and recommendations for needed follow-up. (This report is mandated

by law)

Some possible recommendations by the radiologist or primary doctor if

there is a suspicious area or lump found on the mammogram:

1) Wait 3-6 months and have another mammogram to see if there are

any changes

2) Referral for ultrasound which will show whether a cyst is fluid-filled

or solid

3) Referral to surgeon for biopsy. (At some mammography centers the

mammogram and the biopsy may be done on the same day. It depends

on the capability of the particular center.)

4) Referral for a ductogram (For this procedure, the radiologist takes a very

fine plastic catheter and with a magnifying glass, threads it into the duct,

squirts dye into it, and takes a picture. A ductogram provides a map for

the surgeon to use for a biopsy and may also show the source of your

breast discharge, if you had discharge.)

Possible questions to ask/things to advocate for:

1) If you have a palpable lump, the mammographer should put a marker on

your breast to make sure the lump is identifiable on the film.

2) If you have calcifications, a magnification view is often taken. Sometimes

this step is skipped and you are sent directly for a biopsy. (You should ask

why, if this is the case, especially if surgical biopsy is recommended.)

3) If referred for biopsy, consider a second opinion of the mammogram

at another center. (For some people a center that specializes in

mammography is a better option.) Take your original mammography

films with you.

4) How much time do I have to make a decision about what to do next?

5) Ask how many mammograms the radiologist reads in a year. The accuracy

of the reading varies depending in part on the number of mammograms

someone reads.

6) Check for the FDA/National Mammography Quality Assurance Advisory

Committee certification. It should be posted in the center.

If you need to have a biopsy, there are several types you could have. The type

of biopsy depends in part on whether the lump is palpable (you can feel it)

or not. If the lump can only be seen on a mammogram, it can be approached

by a stereotactic fine-needle biopsy, stereotactic core biopsy, mammotome, or

wire localization biopsy (see below for descriptions). These procedures use the

mammogram or ultrasound to locate the lump before sampling it. If the lump

is palpable, then it can also be tested with fine-needle aspiration or a core

biopsy. Finally, the lump can be removed entirely with an excisional biopsy or

a piece of it can be removed with an incisional biopsy.

Types of needle biopsies:

• Fine-needle biopsy: a thin needle is used to remove fluid/and or cells

from the breast lump. Usually done by a surgeon.

• Stereotactic (x-ray) core biopsy: done basically the same way as above,

using a larger needle and x-ray guidance to the biopsy site. 5-10 core

tissue samples may be taken depending on whether you have a lump or

microcalcifications. This procedure may be done by a surgeon or

radiologist.

• Mammotome biopsy: a variation on the theme of stereotactic core biopsy.

Instead of cutting out core tissue, it is suctioned out. Mammotome

gets out more tissue than the core method and may be better at finding

microcalcifications than other core procedures, because of having a larger

tissue sample.

Types of surgical biopsies:

• Incisional biopsy: the surgeon cuts a sample of a lump or suspicious area

• Excisional biopsy: the surgeon removes all of a lump or suspicious area

and an area of healthy tissue around the edges.

• Wire localization biopsy: the radiologist will insert a thin wire to show

the surgeon where the lesion is. This procedure is used if the lesion

cannot be felt and a needle biopsy is not possible.

Nearly all biopsied fluid or tissue is sent to the lab for evaluation by a

pathologist. A biopsy pathology report will be written by the pathologist. For a needle

biopsy the report is likely to have less information than the report for a

surgical biopsy. You can ask your surgeon or radiologist who performed the

biopsy for a copy of your pathology report.

The results of your biopsy will be either:

a) Biopsy results are negative (no evidence of malignancy). Treatment is

over for now. It will still be important to have your breasts checked

regularly for any future signs of change.

b) Biopsy results are positive (there is evidence of malignancy) The cells did

contain cancer and you will need to make decisions about your treatment

options.

c) Biopsy results are inconclusive

This sometimes occurs in a fine needle biopsy and generally leads to a

surgical biopsy for more conclusive results.

Possible questions to ask:

1) Do you think I need to have a biopsy? If not, why not?

2) What type of biopsy will I have? Why?

3) How long will it take? Will I be awake? Will it hurt? Will first taking a dose

of Tylenol or ibuprofen help and is it okay?

4) How soon will I know the results?

5) What will the scar look like after the biopsy and after it heals?

7) If I do have cancer, who will talk with me about surgery or treatment?

When?

8) How can I be sure my diagnosis is accurate?

9) How will the type of biopsy I have now affect my ability to have a sentinel

node biopsy? (See Possible Surgical Procedures section)

10) How much time do I have to make a decision about a biopsy?

The purpose of the pathology report is to provide your health care team

with information about the surgical specimen or tissue sample they have

taken from your breast. A pathology report for a biopsy often contains much

less information than a surgical pathology report. (An excisional biopsy is generally

the only instance where a pathology report may be as detailed as a surgical

pathology report.)

You can ask your physician for a copy of your pathology reports. IBCA

encourages people to do so, in part so that you can always have a copy with

you when you go for a second opinion. Of course the first opinion physician

will send it to the second opinion physician, but it is always good to have your

own copy with you in case there is a mailing problem.

After a biopsy that is positive for cancer, if you haven’t already seen a

surgeon, you will be referred to one. You may want to do your own research on

surgeons, or consider the possibility of using a multidisciplinary team*

approach. If you choose to get a second opinion on the pathology report,

ask for/find a referral outside the doctor’s treatment team.

Needle Biopsy Pathology Report

A biopsy pathology report describes whether the tissue is non-cancerous or

cancerous. If it is cancerous, the report will often identify what kind of breast

cancer it is. The most common types of breast cancer are: infiltrating /invasive

ductal; invasive lobular; medullary; and in situ breast cancer. (Other common

terms for in situ include: DCIS [Ductal Carcinoma In Situ] and LCIS [Lobular

Carcinoma In Situ]. Some doctors refer to in situ breast cancer as noninvasive

or precancer.) There are also several other types of breast cancer, which are less

common. Breast cancer can occur in combinations of these various types.

Surgical Pathology Report (see Surgical Procedures)

A surgical pathology report (and a report from an excisional biopsy) includes

much more detailed information, mainly because there is much more tissue for the pathologist to analyze. The report generally includes the size of the

tumor, the extent of lymph node involvement, local extent of the tumor, and

other tissue characteristics called biomarkers. This information will be used by

your health care team to determine your treatment.

Possible questions to ask/consider:

1) What stage and type of breast cancer do I have?

2) Do I have a type of breast cancer that should be treated at a specialized

cancer center?

3) If I have breast cancer, will a pathologist with experience diagnosing breast

cancer read my slides? Does the doctor read a high volume of slides?

4) Do you think my biopsy slides should be reread? Why/why not?

5) What are the chances that my cancer has spread beyond my breast?

6) What did the hormone receptor test (testing to see if the breast cancer cells

contain estrogen or progesterone receptors, which helps to determine

treatment) show?

7) What other lab tests were done on the tumor tissue, and what did they show?

8) How will the information you have help in deciding what type of treatment

or further tests will be best for me?

9) IBCA advocates a second opinion on the pathology report and encourages

clients to have their slides sent to a different hospital/medical center than

the one that did the first pathology. (Be sure to have the slides sent in a

way that they can be tracked, i.e., FedEx, registered mail, etc.)

BREAST SURGERY:

Lumpectomy: (Sometimes referred to as breast conserving surgery.) A surgical

procedure that removes the breast cancer and tissue surrounding it. The

amount of breast tissue that is removed depends on the size of the tumor and

how much surrounding tissue is affected by the cancer. This amount can vary

from a small to a large section of the breast.

Mastectomy: a procedure that removes the breast and tissue surrounding the

breast. Mastectomy often includes an axillary node dissection or sentinel node

biopsy (see section on lymph node surgery)

Possible questions to ask your surgeon:

1) What are the advantages and disadvantages of having a mastectomy or a

lumpectomy?

2) Is there a difference in the survival rate between lumpectomy and

mastectomy?

3) What are the risks if I don’t have surgery?

4) How much time do I have to make this decision?

5) What do you need to know about complementary therapies I may be

using? (Some therapies include acupuncture, herbs, biofeedback,

visualization, meditation, yoga, nutritional supplements and vitamins.)

6) If I have a mastectomy, will I be given a temporary prosthesis to go

home with?

7) If my hospital stay is on a weekend, will I see you? When?

LYMPH NODE SURGERY:

Sentinel node biopsy: a small amount of blue dye and/or radioactive fluid is

injected into the breast at the site of the lesion. This material then passes

naturally through the nearby lymphatics to the first draining lymph node (or

nodes) for that area of the breast. (Lymph nodes are located in the armpit and

throughout the chest area.) This is the node that is most likely to have drained

any cancer cells from the lesion area. These first nodes (called sentinel nodes)

are then removed and carefully studied. If they are cancer-free the assumption

is that the nodes further away are also cancer-free. If the sentinel node

contains cancer cells, an axillary node dissection may be performed. Sentinel

node biopsy may reduce the risk of lymphedema.

Axillary node dissection: a procedure that removes more lymph nodes from

the armpit. This procedure is usually done at the same time as breast surgery.

Lymphedema may be a greater risk with this procedure because more nodes

are removed than with sentinel node biopsy.

Lymphedema-Swelling that may occur from an accumulation of

lymphatic fluid that cannot drain as the result of axillary node dissection or

radiation. Swelling may occur occasionally, chronically or only one time. This

swelling can be slight or if it is more extensive can create major discomfort

and result in secondary infections.

Possible questions to ask your surgeon before surgery:

1) Is a sentinel node biopsy possible for me?

2) If I have an axillary node dissection, what problems might result

(short term, long term)?

3) What do you need to know about complementary/alternative therapies I

may be using? (Some of these therapies include acupuncture, herbs, biofeedback,

visualization, meditation, yoga, nutritional supplements and vitamins.)

4) How much time do I have to make this decision?

ANESTHESIA:

For most biopsy procedures, a local anesthetic is used. However, general

anesthesia is sometimes used. General anesthesia is usually used for lumpectomy

and mastectomy. Be sure to tell your anesthesiologist and/or doctor if you’ve

had trouble with anesthesia before (e.g. nausea), prior to surgery. Also, if

you’ve had trouble with anesthesia before and/or you are worried about it, you

can request a consultation with the anesthesiologist before surgery. Tell your

anesthesiologist about any complementary therapies (see above) you are using.

Possible questions to ask your anesthesiologist:

1) How alert will I be during and after surgery? Will I need assistance getting

home?

2) Is it OK to continue taking both prescription and over-the-counter

medications, vitamins, herbs, etc.?

Chemotherapy: the use of a drug or a combination of drugs to kill any

cancer cells that might have escaped the local cancer site. It can be given by

mouth or by injection and is used to treat your whole system. Chemotherapy

treatment is given in cycles: a treatment period followed by a recovery period,

then another treatment period, etc. Most patients have chemotherapy in an

outpatient section of the hospital, at the doctor’s office, or at home.

Immunotherapy: (also called biological therapy) is used to boost the immune

system’s ability to fight disease. Other biological therapies target specific

molecular steps in the development of cancer cells. Herceptin is such a drug

and has been approved for use in metastatic breast cancer.

Hormonal therapy: usually involves taking medication in pill form

(e.g. Tamoxifen, Raloxifene, Arimidex, Aromasin) to prevent estrogen from

stimulating the growth of any cancer cells that remain after surgery. A more

radical treatment would include removing the ovaries. A patient with a strong

family history of breast cancer sometimes opts for removing her ovaries.

Possible questions to ask your oncologist:

1) Why do I need this treatment?

2) What are my alternatives? What are the risks and limitations of each?

3) What drugs are you recommending? What are they supposed to do?

4) Will I have adverse side effects? What can I do about them? What kind of

effect will the treatment have on my immune system?

5) What side effects may I have if I take hormonal therapy?

6) How long will I be on this treatment?

7) Will this treatment affect my ability to get pregnant? If so, what can I do

about it?

8) How much time do I have to make this decision?

9) What do you need to know about the other medicines I am taking

(prescriptions, herbs, vitamins)?

10) What are the risks if I don’t get this treatment? What are the alternatives,

and their risks and limitations?

Radiation treatment usually involves using a linear accelerator machine

that emits radioactive rays focused on the site of the breast cancer and

surrounding tissue. (This is sometimes referred to as external beam radiation).

Treatment usually involves daily sessions 5 days per week for 5 to 8 weeks

either at a clinic or hospital. At the end of the treatment, a “boost” of higher

dose radiation is sometimes given to the site of the breast cancer. In some

facilities, newer equipment is available that allows for intensity-modulated

radiation therapy (IMRT). It delivers radiation therapy in a more precise

manner and at higher doses, minimizing potential damage to surrounding

tissue. If a large tumor is involved, radiation and/or chemotherapy are sometimes

used prior to surgery to shrink the tumor.

Brachytherapy, available at a few hospitals, briefly places radioactive seeds into

the breast at the site of the tumor. This is usually done twice a day over a course

of 5 days. This procedure is only available to people who meet specific criteria.

Possible questions to ask your radiation oncologist:

1) Why do I need this treatment? What are the advantages and disadvantages

of having radiation? And which areas will be irradiated? Why/why not?

2) What are the risks and adverse side effects of this treatment? What is my

risk of developing lymphedema? What effect will it have on my immune

system?

3) When will the treatments begin? When will they end?

4) Am I a candidate for brachytherapy? If so, what are the advantages and

disadvantages?

4) How will I feel during therapy?

5) What can I do to take care of myself during therapy?

6) Can I continue my normal activities?

7) How will my breast look afterward?

8) What do you need to know about complementary therapies I may be using?

9) What are the risks, if I choose not to have radiation?

10) How much time do I have to make this decision?

Some breast cancer patients choose to use healing techniques outside a

traditional or conventional treatment protocol in addition to traditional

treatments. Others choose a completely alternative path. Some complementary/

alternative therapies include acupuncture, herbs, biofeedback, visualization,

meditation, yoga, nutritional supplements, vitamins and others.

Possible questions to ask alternative practitioners:

1) What evidence is there that this treatment works?

2) Are there any studies available regarding the treatment you are

recommending?

3) How will this interact with my conventional treatment (radiation,

chemotherapy, etc.)? (Remember to tell your practitioner all of the

specific drugs being used in chemotherapy, hormonal therapy, etc.)

4) What is the practitioner’s training?

Some things you may want to consider:

1) What do patients say who’ve tried this treatment?

2) Does your doctor recommend it (why/why not?)?

3) Does your insurance cover the cost? How will you pay for it?