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Q. What are the Signs of Breast Cancer? Often there are no outward signs of breast cancer that you can see or feel. If there are outward signs, the more common ones include a lump, an area of thickening, or a dimple in the breast. Less common signs include breast swelling and redness or an enlarged underarm lymph node. But even if you have one or more of these signs, it still doesn't mean you have breast cancer. Remember that most breast lumps turn out to be benign (not cancerous). Q. Can Wearing a Bra all the Time Cause Cancer? Q. Can you get breast cancer from things you do to your breasts, like wearing a bra all the time, or when your partner caresses them? No, you cannot get breast cancer from these things. What you wear and how your breasts are touched do not affect your risk for breast cancer. But if you feel uncomfortable with the way your partner handles your breasts, you need to share that with him or her. It's important for you to be intimate in ways that feel good for you. Dr. Qureshi's advice. Handle with care. Breast Cancer Diagnosis and Treatment Questions To Ask The Doctor I may have breast cancer, what questions should I ask my doctor? If you have received a positive or possible diagnosis of breast cancer, there are a number of questions that you can ask your doctor. The answers you receive to these questions should give you a better understanding of your specific diagnosis and the corresponding treatment. In addition, your doctor's ability to address your questions will give you some assessment as to the quality of care to be provided. Each question is followed by a brief explanation as to why that particular question is important. We will not attempt to answer these questions in detail here because each individual case is just that - individual. This outline is designed to provide a framework to help you and your family make certain that most of the important questions in breast cancer diagnosis and treatment have been addressed. Is the doctor sure I have breast cancer? Certain types of cancer are relatively easy to identify by standard microscopic evaluation of the tissue. This is generally true for the most common types of breast cancer. However, as the search for earlier and rarer forms of breast cancer progresses, it can be difficult to be certain that a particular group of cells is malignant. Benign conditions may have cells which are somewhat distorted in appearance or pattern of growth. For this reason, it is important that the pathologist reading the slides of your breast biopsy be experienced in breast pathology. Most good pathology groups have multiple pathologists review questionable or troublesome slides. In the more difficult cases, the slides will often be sent to recognized specialists with considerable expertise in breast pathology. What kind of breast cancer do I have? Breast cancer is not a single disease. There are many types and they may have vastly different implications. Breast cancers range from localized cancers such as ductal carcinoma in situ (DCIS) to invasive cancers that can rapidly spread (metastasize). In the middle of the spectrum are breast cancers, such as colloid carcinomas and papillary carcinomas, which have a much more favorable outlook (prognosis) than the other more typically invasive breast cancers. Sometimes, noninvasive DCIS is found around invasive breast cancers. What difference does a precise diagnosis make? The importance of an accurate diagnosis cannot be overestimated. It is the precise diagnosis that determines the recommended treatment. Treatment must be specifically tailored to the specific type of breast cancer as well as to the individual patient. Your doctor should be able to give you a clear description of your type of breast cancer along with the treatment options that are appropriate to your case. What has been done to exclude cancer in other areas of the same breast or in my other breast? Unfortunately, there are some patients who may have more than one area of malignancy in the same breast or even an additional malignancy in the other breast. If this does occur, it can greatly change the recommendations for treatment. Therefore, it is critically important that your doctors carefully investigate beyond the immediate site of the tumor to make certain there are no other areas with possible malignancy. Not all imaging centers are aggressive enough in this search. Sometimes discovering these "secondary" areas requires careful review of your mammograms. It may also require the addition of special views from different angles and specialized ultrasound examination of your breasts. This technology may only be available at centers with special expertise in breast imaging. What type of medical team do I need for the most accurate diagnosis? The best medical centers have a well-coordinated team which includes the pathologist, surgeon, and radiologist. The input of the team must be available during biopsies and any tumor-clearing surgery to ensure the best chance of a favorable outcome for the patient. How important is the role of the pathologist reading my slides? The pathologist evaluating the slides made from fine needle aspiration biopsies, core biopsies, and tissue slides of the breast must have a great deal of experience and special training. It is important that the pathologist reliably determine the presence or absence of cancer and distinguish cancer from other conditions such as hyperplasia with atypia ( an overgrowth with unusual looking but benign cells). Have my slides been reviewed by more than one pathologist? A review by more than one pathologist is optimal. There are many subtleties which can be overlooked when reviewing microscope slides. These can lead to both over-reading (making a false positive diagnosis) and under- reading (making a false negative diagnosis). When slides are read a second time by another pathologist followed by a discussion of the conclusions, most diagnostic problems are resolved. In good centers there are almost always several pathologists available who can review the pathology of your slides (this is termed a "double reading"). The added safeguard of double reading may not be necessary in most cases of breast cancers but can be a critical factor in some cases. Can I have my biopsy reviewed by a pathologist at another diagnostic center? It should always be possible to send slides from your biopsy to a pathologist at another diagnostic center. First of all, there should not be a rush to treatment; breast cancer is almost never an emergency. Developing the best treatment plan depends on a good thorough pathologic evaluation as well as a complete work-up of both breasts, as noted above. Second, good pathologists are never offended by a request for an outside opinion. They also usually know the names of some of the finest breast pathologists in the country and should be willing to arrange a consultation with one of these doctors. In most cases of breast cancer, it is not necessary to obtain this in-depth consultation. However, if there are any unusual aspects of your case, it can be important in your decision-making process. The matter of obtaining additional consults may take a week or more. Is my family history relevant to my diagnosis? If you have a strong (positive) family history for breast cancer, ovarian cancer or even prostate cancer, this information is relevant to your diagnosis. A strong family history in this case usually means that a mother, sister, daughter or father have had a related malignancy. Information about other family members (aunts, nieces, etc.) is also important. This is especially significant if the diagnosis of breast cancer was made at an early age or involved both breasts or a breast and an ovary in the same individual. A positive family history may necessitate a more comprehensive diagnostic work-up, more involved treatment and consideration of genetic testing, not only for you but for other family members. What other studies should be done on my tissue biopsy? Microscopic evaluation of the slides made from involved tissue provides critical information about the tumor. A reasonably accurate prediction of tumor behavior can be made based on the appearance of the cancer cells, their size and similarity to one another, and the presence or absence of these cells in the lymphatic and blood vessels immediately adjacent to the tumor. This type of evaluation is a standard part of the diagnostic process. However, there are additional relevant data which the laboratory should obtain. This information includes, at a minimum, an assessment of the estrogen and progesterone receptors on the malignant cells and the status of at least one oncogene, called her-2-neu. An oncogene is a gene that plays a normal role in cell growth but, when altered, may contribute to abnormal cell division and tumor growth. Currently, these tests (estrogen and progesterone receptors and her-2-neu) have an accurate enough predictive value that their status should be determined in all cases of breast cancer. Test results are available within a few days to a week after removal of the tumor tissue. The results of these tests should then be taken into account in the final decision-making about treatment. How urgent is it that I make decisions and begin treatment? It is extremely rare that a patient must be rushed into treatment. The biology of breast tumors is established fairly early in their development and by the time the tumors are detectable, most have been growing undetected for considerably more than a year. This means that if you take a few weeks to complete a thorough evaluation, obtain appropriate consultations, understand the situation, discuss the alternatives and initiate a treatment plan, it is not likely to add any significant risk. This time frame, however, should allow the facts of your case to be carefully sorted out and errors to be minimized. Are there controversies in the recommended treatments among reputable experts? Doctors may differ in their recommendations if they weigh the risks differently. There will always be uncertainties in any given case. These issues are rarely "right versus wrong". They can be compared with decisions such as "how do I balance my desire to have the largest and safest car with the need to have convenience and economy?" There are tradeoffs. For example, certain breast cancer treatment options may favor cosmetic appearance but slightly increase the risk of recurrence in the affected breast. How might my treatment affect future risks and follow-up treatment? There are often indirect consequences of treatment decisions. For example, breast conservation therapy achieves, as its goal, treatment of the breast cancer along with preservation of the breast. This is clearly a highly desirable objective. However, in doing so, it leaves the possibility that cancer may recur in that breast. The risk is small, but is definitely there. Most of the time, the recurrence will be recognized and the new tumor treated early, but not always. These risks mean that a patient choosing breast conservation therapy must have the treated side (and the other breast as well) carefully monitored with regular examinations and imaging tests. Occasionally, tissue abnormalities develop which may suggest a new or recurrent cancer, thereby necessitating further evaluation with more tests or even another biopsy. The majority of these abnormalities turn out to be benign, perhaps caused by benign breast disease or changes from the surgery and radiation therapy. But the psychological impact of having to repeat such an evaluation may be very upsetting to some patients. Breast conservation is not for every breast cancer patient. There are similar considerations in each treatment plan which have to be understood and carefully evaluated before committing to a particular method of therapy. You should discuss these issues thoroughly with your doctor. Should genetic testing be part of the treatment decision process? The majority of breast cancers occur as unconnected (sporadic) cases and are not caused by an inherited genetic abnormality (mutation) passed from parent to child. However, if you have close family members, such as a mother or sister, who have had the disease, especially if it occurred at a young age, then the possibility of a genetic predisposition should be investigated. In these situations, genetic testing may provide valuable information. The test results may affect not only recommendations for your therapy but may also have major implications for other family members as well. Gene testing should only be done after careful genetic counseling so that everyone has a thorough understanding of the potential value and also the limitations of these tests. Should I stop taking hormone replacement therapy (HRT)? Breast cells are programmed to respond to certain hormones as signals for growth and multiplication. The most prominent examples of these hormones are estrogens and progesterones. Many breast cancer cells retain hormone receptors (molecular configurations on the cell surface to which the hormones bind). The hormone receptors therefore make the cancerous cells responsive to these particular hormones. In general, taking hormones is not recommended if a diagnosis of breast cancer is under consideration. This does not necessarily mean that you can never resume hormone replacement therapy. This issue is generally reconsidered after the completion of your evaluation and treatment. Even though my breast tumor does not have hormone receptors, should I take tamoxifen to reduce the risk of a new tumor? Following completion of your treatment for breast cancer, whether or not tamoxifen is prescribed should at least be addressed. In many cases, the primary breast cancer for which the patient is being treated may not be hormone receptor positive. In these cases, tamoxifen (which binds to the estrogen receptor in place of estrogen) is not generally part of the treatment protocol. However, the Breast Cancer Prevention Trial (a study of the use of tamoxifen) demonstrated a significant reduction in the development of new cancers in the opposite breast in patients who were treated with tamoxifen. So, the possible use and benefits of tamoxifen should not be ignored. A thoughtful evaluation of all the factors in a particular case will lead to a recommendation which balances the benefits of tamoxifen against the potential risks. I have a ductal carcinoma in situ (DCIS), a type of localized cancer. Why have I been advised to have a mastectomy when other women with invasive cancer have lumpectomies? Ductal carcinoma in situ (DCIS) sometimes presents a difficult dilemma. Most patients with DCIS can undergo successful breast conservation therapy, but not all. The diagnosis implies that this is an "early" form of cancer in the sense that the cells have not acquired the ability to penetrate normal tissue barriers or spread through the vascular or lymphatic channels to other sites of the body. However, the millions of cells forming the DCIS have accumulated a series of errors in their DNA programs which allow them to grow out of control. There are varying degrees of disturbance, called "grades," of the normal cellular patterns. Low grades are more favorable and high grades are less favorable. The DCIS cells originate from the inside of the breast gland ducts (microscopic tubes). As they multiply, the cells fill and spread through the normal ducts of the breast glandular tissue. With many DNA errors already in place and millions of these cells exposed to the usual risks of additional DNA damage, a few cells will ultimately become invasive. This invasive change is the real risk of DCIS. Treatment which does not physically remove all of the DCIS seems to leave a substantial risk of recurrence and, therefore, invasive disease. This risk of recurrence is particularly increased in the high grade form of DCIS. In cases where the DCIS has spread extensively through the breast ducts, even though the disease is in a sense "early" because it is not yet invasive, it may still require a large surgical resection, at times even a mastectomy (removal of all or part of the breast). Should I start chemotherapy before surgery? The classical concept of breast cancer treatment has been a sequence of tumor-removing surgery followed by chemotherapy and/or radiation therapy. The goal of surgery and radiation therapy is to destroy or remove the primary cancer. Follow-up chemotherapy is designed to eliminate any cancer cells, as yet undetectable, at remote sites. Recently there have been new findings suggesting a potential benefit in some patients when chemotherapy is started before surgery. However, initial chemotherapy (neoadjuvant chemotherapy) should primarily be considered in patients with larger tumors and those with strong evidence of lymph node involvement at the time of initial diagnosis. If I am advised to have a mastectomy, what are the risks and benefits of immediate breast reconstruction? If a mastectomy is necessary, immediate reconstruction offers a great psychological benefit to most women. However, as is often the case in medicine, there are trade-off risks which must be considered. If the reconstruction is done during the same surgery as the mastectomy (immediate reconstruction), the final results of the pathology tests on the removed tumor and tissue is not yet known and will not be known for at least a day or two. There are sometimes findings on the final pathology report which make chest wall radiation advisable in order to reduce the risk of local recurrence. If a prosthesis for the breast has been implanted, the radiation treatment will still work, but the radiation may significantly compromise the cosmetic appearance of the prosthesis. There may also be healing problems which delay chemotherapy, potentially increasing the risk of breast cancer recurrence. These and other factors should be discussed and carefully considered before committing to immediate breast reconstruction. Should my lymph nodes be removed? Lymph nodes are small glandular structures that filter tissue fluids. They filter out and ultimately try to provide an immune response to particles and proteins which appear foreign to them. There are thousands of these nodes scattered in groups throughout the body. Each cluster is more or less responsible for the drainage of a particular region of the body. The lymph nodes under the arm (axillary nodes) are the dominant drainage recipients from the breast. When cancerous cells break free from a breast cancer, they may travel through the lymph tubes (vessels) to the lymph nodes. There, the cancerous cells may establish a secondary growth site. The presence of cancerous cells in the lymph nodes proves that cancer cells have traveled away from the primary breast tumor. Therefore, the presence or absence of cancer cells in these regional nodes is an important indicator of the future risk of recurrence. This information is often important in making decisions about whether to use chemotherapy and what type of chemotherapy should be employed. Unfortunately, removal of the lymph nodes also carries a potential risk of lymphedema, a condition that may cause the arm to swell. Lymphedema can occur early after surgery or many years later. It can be a difficult and disabling condition. Here again, there are trade-offs in risk. When more lymph nodes are removed, more accurate the information about tumor spread is obtained and the chance for tumor recurrence is less. But, there is a greater incidence of lymphedema. There are alternatives to standard lymph node removal (called axillary node dissection). These alternatives should be considered in each patient's situation. They include: 1. Replacing standard axillary node removal with sentinel node biopsy (explained below); 2. Not doing lymph node removal in patients who will receive chemotherapy anyway based on other information; and 3. Not doing lymph node removal in patients with very small or "favorable" tumors. Again, these alternatives must be selectively applied, with the benefits and risks carefully evaluated. What is a sentinel lymph node biopsy and what are its benefits and risks? A sentinel node biopsy takes advantage of a peculiar physiologic and anatomical finding. Although there may be many lymph nodes in a particular drainage region, it appears that only one or two are the first recipients of the regional fluids. This means that if any nodes will be involved by tumor spread, the sentinel node will be the first. It also means in general that if the sentinel node is not involved, then no other nodes will be affected. Therefore, only the sentinel node needs to be removed. There are techniques for removing just the sentinel nodes. A sentinal node biopsy allows the pathologist to more intensively study this node and apply specialized techniques that are capable of detecting even a few cancer cells. This technique is still in the investigational stage. It is relatively new to breast cancer treatment. More patients must be followed long-term before the effectiveness of this new therapy is understood. However, currently available early studies and evidence strongly support its value. This procedure seems to provide the needed pathological information and reduces the risk of lymphedema. Are there any other questions I should ask my doctor? Yes. There are surely other questions you will wish to ask. Do you have any questions for me. Does anyone else have a better answer? Would you like to print Dr. Q's research and development in Oncology? admin@qureshiuniversity.com