CLINICAL

INFORMATION

BREAST

AWARENESS

We encourage all women to be aware of how their breasts look and feel normally and report any changes to their doctor. Finding a change does not mean that you have cancer.

By being aware of how your own breasts look and feel, you will be more likely to notice any changes that might take place. You can also choose to use a step by step approach to checking your breasts on a set schedule.

The best time to do a breast self-examination (BSE) is when your breasts are not tender or swollen, so avoid the days just before your period or during your period.

Look for these changes: a lump or swelling, skin dimpling, nipple turning inward, redness or scaling of the nipple or breast skin, a discharge from the nipple other than breast milk, a lump under the arm.

Remember- most of the time these breast changes are not cancer.

Guide to Breast Self Examination

BREAST CANCER

SCREENING

The term screening refers to tests and examinations used to find a disease like cancer in people who do not have any symptoms or signs or who have not noticed any breast changes. The earlier a breast cancer is found, the better the cancer's treatment will work and therefore the better the outcomes. The goal of screening is to find the cancer before it starts to cause symptoms. Most doctors feel that early detection tests for breast cancer save many thousands of lives each year. The guidelines for screening differ in different countries but generally include the following:

 

Mammogram: Women over 40 should ask their doctor how often to go for a mammogram. While mammograms can miss some cancers, they are still a very good way to find breast cancer including the "in situ" cancers ie: cancers that are not yet invasive. A mammogram is an X-ray of the breast. Very low levels of radiation are used. The breast is flattened between 2 Xray plates and, although this may be uncomfortable, it only lasts a few moments and is required to get a good picture.

 

Clinical breast examination (CBE): Women in their 20's and 30's should have CBE as part of their regular examination by a health expert at least every 3 years. After age 40, women should have a CBE every year.

 

Breast self-examination (BSE): BSE is an option for women starting in their 20's. Women should be told about the benefits and limitations of BSE. If you do a BSE on a regular basis, you get to know how your breast normally look and feel and can more easily notice changes. Any worrying changes should be reported to your health professional.

 

Women at high risk: Women who have a higher risk of breast cancer should discuss with their doctor the best approach for them. This may mean starting mammograms when they are younger, having extra screening tests or more frequent examinations.

 

DIAGNOSIS

If  you discover a breast lump or breast change, an appointment should be made with your doctor or nurse for a clinical assessment.

They will advise whether further tests are needed.

Three approaches are usually involved in investigating breast diseases:

 

1. A physical examination:

 The examiner will first look at your breast for changes in size or shape.

 Then using the pads of the fingers he/she will gently feel your breasts for

 lumps.  The area under your arms will also be checked.

 

2. Imaging:

 

 Mammogram: This is usually the first imaging examination that is

performed in women over 40 years of age.  It is an x-ray of the breast.  Very low levels of radiation are used.  The breast is pressed between two plates to flatten and spread the tissue. The pressure may cause some discomfort during the short while it takes to take the X-Ray.

 

Ultrasound: In women younger than 30 years or depending on the results of the  mammogram in an older woman, an ultrasound may be requested.  The ultrasound uses  high frequency sound waves to obtain images.

 

Magnetic Resonance Imaging (MRI): The MRI is of limited use in breast screening but  may be indicated in woman who have a genetic mutation and are at extremely high risk for  breast cancer.

 

3. Biopsy:

 

The Fine Needle Aspiration Biopsy (FNA or FNAB):

This is the least invasive biopsy method.  Small amounts of cells are aspirated (sucked up)  into a syringe through a needle: a bit like a blood test.  No stitches are needed.  The  procedure can be performed in your Doctor’s office and takes only a few minutes. Results  are usually available later the same day or within 24 hours.

 

Core biopsy:

This can also be performed in your Doctor’s office but requires a local anaesthetic to numb  the area.  These core biopsies provide a larger tissue sample but may not be suitable for  patients with a very small or hard lump.

 

Biopsies could also be conducted under ultrasound guidance or stereotactic (mammographic) guidance if the area of abnormality is not in the form of an “easy-to-feel” lump.

 

 

BENIGN

BREAST LUMPS

Most breast lumps are benign which means they are not cancers. They do not spread outside of the breast and they are not life threatening. But some benign breast lumps can increase a woman's chance of getting breast cancer.

 

So, if a breast lump is not a cancer, what could it be?

 

Fibroadenomas: solid, smooth, rubbery lumps that move around easily in the breast tissue. They consist of fibrous (or connective) tissue and normal glandular tissue of the breast.

 

Lipomas: benign growths of fat cells.

 

Cysts: small sacs of fluid within the breast tissue.

 

Fibrocystic change: small fluid filled sacs called "cysts" become entrapped in dense fibrous tissue within the breast. May present as breast lumpiness, thickening, and/or swelling which may be tender or painful.

 

It is important that all breast lumps are investigated fully before diagnosis is made.

BREAST

CANCER

Symptoms and Signs:

 

The widespread use of screening mammograms has increased the number of breast cancer found before they cause any symptoms.

 

The most common sign is a breast lump. A lump that is painless, hard, and has uneven edges is more likely to be cancer. However some cancers are tender, soft and smooth. So it's important to have any lump or breast change checked by a doctor.

 

Other signs that could sometimes suggest breast cancer are:

 

  • Swelling or change in size of the breast.
  • Skin irritation or dimpling.
  • Nipple change - pain or retraction (pulling inwards).
  • Rash, redness, scaling or thickening on or around the nipple or breast skin.
  • Nipple discharge.
  • Lump under the arm.

 

What causes breast cancer?

Certain changes in DNA can cause normal breast cells to become cancerous. DNA makes up our genes which code for the instructions for how our cells work. Some inherited DNA changes can increase the risk for developing cancer are responsible for cancers that run in some families.

RISK

FACTORS

Certain risk factors are linked to the disease.

A risk factor is anything that increases a person's chance of getting a disease such as cancer. Some risk factors are linked to a persons lifestyle choices and can be changed, such as smoking, drinking of alcohol and diet.

Other risk factors such as a person's age or family history cannot be changed.

Having a risk factor, or even a gene, does not mean that you will definitely get the disease. Some women who have one or more risk factors never get the breast cancer, and many women who develop breast cancer don't have any risk factors.

While all women are at risk for breast cancer the factors below may increase a woman's chances of developing the disease.

 

Risk Factors you cannot change:

 

Gender:

Simply being a woman increases the risk of developing breast cancer over a man's. While men also get breast cancer, it is 100 times more common in women that in men.

 

Age:

This is the strongest risk factor for developing breast breast cancer. The chance of getting breast cancer increases as a women gets older. About 2 out of 3 women with invasive breast cancer are age 55 or older when cancer is found.

 

Personal History of breast cancer:

A woman with cancer in one breast has a greater chance of getting a new cancer in the other breast or in another part of the same breast. This is different from a return of the first cancer (which is called recurrence).

 

Family History:

Breast cancer risk is higher among women whose close blood relatives have this disease. The relatives can be from either the mother's or father's side of the family. The more family members affected, the younger they were at diagnosis and the closer they are related: the higher the chance of breast cancer in that individual.

 

Genetic:

Breast cancers linked to positive genes make up the minority (5-10%) of breast cancer cases. The most common gene changes that have been identified as being linked with breast cancer are those of the BRCA1 and BRCA2 mutations. Women with these gene changes have an increased risk of getting breast cancer during their lifetimes.

 

There are tests that can tell if a woman has certain changed (mutated) genes linked to breast cancer. With this information, women can then take steps to reduce their risks. If you are thinking about genetic testing, you should talk to a genetic counselor, nurse or doctor qualified to explain the nature and possible outcomes of these tests. It is very important that you know what genetic testing can and can't tell you, and to carefully weigh the benefits and risks of testing before these tests are done.

 

Dense breast tissue:

Dense breast tissue means there is more glandular tissue and less fatty tissue. Women with denser breast tissue have a higher risk of breast cancer. Dense breast tissue can also make the breast tissue can also make the breast more difficult to examine and more difficult for doctors to identify problems on mammograms.

 

Menstrual periods:

Women who began having periods early (before age 11) or who went through the change of life (menopause) after the age of 55 have a slightly increased risk of breast cancer.

 

Risk Factors influenced by lifestyle choices.

 

Not having children or having them later in life:

Women who have not had children, or who had their first child after age 30, have slightly higher risk of breast cancer.

 

Use of birth control pills:

Studies have found that women who are using birth control pills have a slightly greater risk of breast cancer (however, also a lower risk of ovarian cancer!) than women who have never used them. Women who stopped using the pill more than 10 years ago do not seem to have any increased risk. It's a good idea to talk to your doctor about the risks and benefits of birth control pills.

 

Hormone replacement therapy (HRT):

Has been used for many years to help relieve symptoms of menopause and to help prevent thinning of the bones (osteoporosis). It has become clear that long-term use (several years or more) of the combined forms of HRT increases the risk of breast cancer. There are some good reasons to use HRT other than for short-term relief of menopausal symptoms. Because there are other factors to think about, women should talk  with their doctors about the advantages and disadvantages of using HRT. If a woman and her doctor have decided to try HRT purely for relief of menopausal symptoms, it is usually best to use it at the lowest effective dose and the shortest time possible.

 

Not breast-feeding:

Some studies have shown that breast-feeding slightly lowers breast cancer risk, especially if the total combined time of breast-feeding lasts at least a year or 2.

 

Alcohol:

Use of alcohol is clearly linked to an increased risk of getting breast cancer. Try to limit the amount to one drink a day, if at all.

 

Being overweight or obese:

Being overweight or obese is linked to a higher risk of breast cancer, especially for women after menopause if the weight gain took place during adulthood. Also the risk seems to be higher if the extra fat is in the waist area. The link between weight and breast cancer is complex. It is recommended to maintain a healthy weight throughput life.

 

Lack of exercise:

Studies show that exercise reduces breast cancer risk. This may be because exercise helps control weight. The only question is how much exercise is needed.

 

High fat diets:

Studies found that breast cancer is less common in countries where the typical diet is low in fat. Eating a healthy, low fat diet that includes 5 or more servings of vegetables and fruits each day, choosing wholegrain products instead of refined starches, and limiting the amount of processed and red meats is recommended.

 

Tobacco smoke:

A possible link to breast cancer is another reason to stop smoking and avoid being around secondhand smoke.

Many of us can make some adjustments to our lifestyle choices which may lower our risk of getting breast cancer.

For more information about risk factors for breast cancer go to:

https://www.cancer.org/cancer/breast-cancer/risk-and-prevention.html

 

What if you are at increased risk?

There are some things you can do to reduce your chances of getting breast cancer if you are at an extremely increased risk based on your family history or genetics. This could include chemoprevention or preventive surgery. Before deciding which, if any, of these may be right for you, talk with your doctor.

Chemoprevention:

Chemoprevention is the use of drugs to reduce the risk of cancer. Many drugs have been studied for use in lowering breast cancer risk.

Preventative surgery for women with very high breast cancer risk:

For the few women who have a very high risk for breast cancer, preventative surgery such as bilateral (double) mastectomy, or oophorectomy (removal of the ovaries) may be an option. The reasons for thinking about this type of surgery need to be very strong. There is no way to know ahead of time whether this surgery will benefit a particular woman. A second opinion is strongly recommended before making a decision to have this type of surgery.

BREAST CANCER

TERMINOLOGIES

Breast tissue that has been removed by biopsy is sent to the pathology laboratory for analysis: A description of the cells may involve the following terms:

 

Benign:

Benign tumors are not cancerous. Some may grow or increase in size, but they do not spread outside the breast and are not life threatening.

 

Malignant:

Malignant tumors are what are referred to as breast cancer. Cells of malignant tumors have the potential to break off from the main tumor or cancer. From there they can spread to the lymph nodes via the lymphatic ducts, or to more distant organs via the blood stream.

 

It can be hard to understand some of the words you come across when talking or reading about breast cancer.

There are many kinds of breast cancer. They are described in terms of their type, their grade and their receptor status. Different kinds of breast cancers behave differently and will respond to different treatments than others. This is important in guiding the treating team in selecting the most appropriate therapies for each individual patient.

TYPES OF

BREAST CANCER

Carcinoma: a cancer that begins in the lining of the breast ducts (Ductal Carcinoma) or lobules (Lobular Carcinoma).

 

Adenocarcinoma: a cancer that starts in glandular tissue (tissue that makes or secretes a substance). The ducts and lobules of the breast are glandular tissue (they make breast milk), so cancers that start in these areas are sometimes adenocarcinomas.

 

Carcinoma in situ: this term is used to describe the earliest stage of breast cancer, when it is still only in the layer of cells where it began. In breast cancer, "in situ" means that the cancer cells are still only in the ducts (ductal carcinoma in situ - DCIS) or in the lobules (lobular carcinoma in situ - LCIS). The cancer cells have not yet invaded the breast tissue. They are sometimes referred to as non-invasive breast cancer.

 

Invasive (or Infiltrating) Carcinoma: An invasive cancer is one that has grown beyond the layer of cells where it started (unlike carcinoma in situ). Most breast cancers are invasive carcinomas - either invasive ductal carcinomas or invasive lobular carcinomas.

 

Sarcomas: These are cancers that start from connective tissue like muscle, fat or blood vessels. Sarcomas of the breast are rare. Sometimes a breast tumor can be a mix of these types or a mixture of invasive and in situ cancer.

 

Sometimes a breast tumor can be a mix of these types or a mixture of invasive and in situ cancer.

STAGES OF

BREAST CANCER

Breast tumors are often described by stage. Staging takes into account the size of the tumor, where there are any lymph nodes involved, and whether it has spread far from its original site or metastasised. It is an induction of the distance it has spread and not necessarily how that tumor will behave.

 

Breast cancer cells could spread through either the lymphatics (to the lymph nodes) or the bloodstream to other parts of the body via the bloodstream such as the bones, lungs and liver.

Simplified stages of breast cancer are:

 

Stage 0: non invasive (in situ).

 

Stage 1: invasive but less than 2cm in size and no lymph nodes involved.

 

Stage 2: invasive with asize of 2-5cm, or smaller but spread to a few lymph nodes in the armpit.

 

Stage 3: size more than 5cm, or smaller but spread to many lymph nodes which become stuck to one another or has spread to the breast skin, chest wall or internal mammary lymph nodes.

 

Stage 4: spread to more distant organs.

GRADES OF

BREAST CANCER

Grading of a Breast Cancer is based on the microscopic appearance of the tumor cells and give an indication of the rate (speed) of growth.

Simplified grades of breast cancer:

 

Grade 1: cells look relatively normal = well defined, slow growing.

 

Grade 2: characteristics between Grade 1 and 3 = moderately differentiated.

 

Grade 3: cells lack normal features = poorly differentiated - tend to grow much quicker.

 

The grade of a tumor is related to prognosis. The grade 1 or low grade tumor has a better prognosis because it grows more slowly and tends to spread later than higher grade tumors.

BREAST CANCER

RECEPTORS

Some breast cancer cells have high numbers of receptors for some hormones or growth factors which can influence their growth. The laboratory can do tests for these on the tissue sample from the biopsy.

Hormone receptor positive:

If there are high numbers of oestrogen receptors (ER) or progesterone receptors (PR) reported on the pathology report, the cancer will be called ER or PR positive. This is important to know in order to plan treatment, as hormone receptor positive breast cancers will respond well to anti-hormonal treatment (such as Tamoxifen or Aromatase Inhibitors).

 

HER2 receptor positive:

If there are high numbers of receptors to the human epidermal growth factor receptor 2, the cancer will be called HER2 positive. HER2 positive tumors tend to be fast growing. They also respond to the HER2 targeted therapy called Herceptin.

TREATMENT OF

BREAST CANCER

Treatment of breast cancer is individualised according to the type, grade, stage and receptor status of the cancer and also the age and health status of the patient. Therefore advised treatment plans may differ between patients. General types of treatment can be put into broad groups, based on how they work and when they are used. Combinations of the various treatments are often advised for individual patients with breast cancer.

LOCAL VS SYSTEMIC

TREATMENT

The purpose of local treatment is to treat a tumor without affecting the rest of the body. Surgery and radiation are examples of local treatment.

 

Systemic treatment is given into the bloodstream or by mouth to go throughout the body and reach cancer cells that may have spread beyond the breast.

Chemotherapy, hormone therapy, immunotherapy and biologial therapy are systemic treatments.

ADJUVANT VS NEO-ADJUVANT

TREATMENT

Cancer cells may break away from the main tumour and spread through the bloodstream even in the early stages of the disease. It is very hard to tell if this has happenend. But, if it has, theses cellss can start new tumours in other organs months or years later. Therefore a patient, depending on the type, stage, grade and receptor status of the cancer, may be advised to have certain treatements after their surgery in order to kill these hidden cells. This is called Adjuvant therapy.

 

Neo-adjuvant therapy is when patients have systemic therapy BEFORE their surgery either to shrink a cancer before the operation, or if the operation needs to be delayed for some reason.

 

SURGERY

Most women with breast cancer will have some type of surgery to treat the main breast tumor. The purpose of surgery is to remove as much of the cancer as possible. Surgery can also be done to find out whether the cancer has spread to the lymph nodes under the arm (sentinel lymph node biopsy). Plastic and Reconstructive or cosmetic surgery can be done to improve the breasts appearance after the surgery.

 

Breast Conserving Surgery: Lumpectomy (Wide Local Excision) and Partial mastectomy are examples of breast conserving surgery. In these types of surgery, only part of the breast is removed and needs to be followed by radiation therapy:

 

Lumpectomy or Wide Local Excision: this surgery involves removing only the breast lump and a margin of normal tissue around it. Radiation treatment is usually given after this type of surgery. If chemotherapy is also going to be used, the radiation may be delayed until the chemo is finished.

 

Partial Mastectomy: this surgery involves removing more of the breast tissue than in a wide local excision. It is usually followed by radiation therapy.

 

Mastectomy: Mastectomy involves removal of the whole breast.

 

Reconstructive surgery: these operations do not treat the cancer, but can be done to restore the way the breast looks after the cancer has been surgically removed. There are several choices about what type of reconstruction can be done and whether it is done at the time of the cancer surgery, or delayed until after all treatment. This should be discussed with your surgeon and a plastic surgeon before the cancer surgery is performed.

 

Complications of surgery: possible surgical complications can include bleeding, pain, infection, temporary swelling, seroma (pocket of clear or bloodstained fluid collecting at incision site), shoulder stiffness, numbness, thickened tissue due to scar tissue that forms at the surgical site. Complications are more common in smokers, diabetics, older patients and those who have had previous radiotherapy.

The simpler the surgery, the less likely the complications.

 

Lymphoedema is an important complication:

If lymph nodes are removed from under the arm, lymphoedema may occur. Lymphoedema is swelling (usually of the arm in the case of breast surgery and/or radiation) caused by disruption to the lymphatic drainage system leading to lymphatic fluid build up. It can occur any time after treatment for breast cancer - right after surgery, months or even years later. Lymphoedema is treatable but not curable, so is best prevented or at least diagnosed as early as possible and kept under control. Injury or infection of the arm on the affected can cause lymphoedema or make it worse. Tell your doctor right away about any swelling, tightness or injury to the hand or arm. Lymphoedema should ideally be treated by a trained Lymphoedema therapist (usually a physiotherapist, occupational therapist or nurse) working together with the patient and the family. Most of the time, there is some improvement. If the Lymphoedema has been there for a long time, there are changes to the soft tissues in the arm which may not be reversible. As a result the arm may be permanently swollen. Therefore, it is important to start management for lymphoedema early to try and prevent a chronic problem. Preventative strategies include using gloves when gardening and avoiding having intravenous drips, blood drawn from or blood pressure taken on the arm on the side of the lymph node surgery or radiation.

Contact CANSA toll-free 0800226622 for information about lymphoedema clinics near you.

 

RADIOTHERAPY

RADIOTHERAPY: (also called radiation therapy, or radiation oncology) is the medical use of ionising radiation or high energy rays to damage cancer cells and stop them growing and dividing. Like surgery it is a highly targeted local treatment which affects cancer cells only in the treated area.

 

Radiotherapy for breast cancer can be used:

 

  • after lumpectomy or mastectomy, either alone or in combination with chemotherapy and/or hormone therapy.
  • as the main treatment if the tumor cannot be safely surgically removed or the person's health does not allow for surgery.
  • to treat the bones or the brain if the cancer has spread there.
  • to relieve pain, or assist in reducing the leaking or bleeding of open wounds of locally advanced cancer.

 

Side effects/complications:

These depend on the treatment dose and the part of the body that is treated:

The most common side effects are tiredness, loss of appetite, breast swelling/tenderness, skin rash/redness or hair loss in the treated area. Some patients may find the breast skin more sensitive after radiation while others may find it less sensitive. Some skin changes can look similar tot he changes seen in breast cancer.

Most of the side effects are not acute, and because the patient is usually being seen every day by the treatment team, they can be effectively managed.

For more information and tips on how to manage side effects please go to__________

 

Lymphoedema: as with surgery, radiotherapy may increase a patient's risk of developing Lymphoedema (swelling) of the arm. The risk is higher for patients who have had radiotherapy as well as having had auxiliary lymph nodes removed.

 

CHEMOTHERAPY

Chemotherapy drugs are used to kill cancer cells throughout the body. They work by disrupting the mechanics of cell division. Cancer cells are known to divide and replicate and grow much faster than normal cells and are therefore more susceptible to chemotherapy drugs. Many different types of chemotherapy drugs are used to treat different cancers and each drug works at a slightly different part of the cell division process. The treatment may include more than one drug and this is called combination therapy. A combination of drugs with different actions may work together to kill more cancer cells and reduce the chance that the cancer may become resistant to any one particular drug.

 

They are usually given by through an intravenous drip (or, in some cases, tablets by mouth) with the aim of travelling through the bloodstream to reach more distant parts of the body. Chemotherapy is normally given in an outpatient clinic so patients can go home the same day.

 

Chemotherapy can be given in different situations which will vary according to each individual patient's situation:

 

  1. ADJUVANT CHEMOTHERAPY: (Treatment after surgery):                                                                                                        There is the possibility that, before the time of surgery, a few cancer cells may have broken away from the main tumor and spread through the bloodstream to settle in other places such as lymph nodes, bone liver, brain or lungs. These may start growing and cause problems sometimes many years after initial treatment. The aims of adjuvant treatment is to kill these hidden cells and reduce the risk of future recurrence. Not every patient needs adjuvant chemotherapy as some patients are not a high risk of this happening, and some breast cancer types do not succumb to chemotherapy as much as others.
  2. NEO-ADJUVANT: (Treatment before surgery):                                                                                                                            The main benefit of this is to shrink large cancers so that they are small enough to be removed safely or to improve cosmetic outcome. Another advantage is that doors can monitor how the cancer responds during chemotherapy.
  3. ADVANCED METASTATIC CANCER:                                                                                                                                 Chemotherapy can also be used as the main treatment for cancer that have already spread outside the breast and armpit at the time it is found, or if it spreads after the first treatments.

 

Possible Side Effects:

Chemotherapy drugs cannot distinguish between cancer cells and normal cells and may therefore affect some normal rapidly dividing cells in the body such as hair, skin, nails, lining of the digestive system and bone marrow (blood cell lines).

Therefore there are various side effects associated with the therapy and because each drug acts in a slightly different way, the side effects will also differ between the drugs.

 

Some side effects include: tiredness/fatigue (caused by low red blood cells) - anaemia, higher risk of infection (caused by low white blood cells) - neutropaenia, easier bruising/bleeding (caused by low platelet counts), hair loss, mouth sores, skin/nail changes, nausea / vomiting / diarrhoea / constipation, loss of appetite, peripheral neuropathy, changes in menstrual cycle and fertility.

 

Please go to ______________for more information on side effects, how to manage them and when to contact your doctor.

 

Blood cell counts are tested routinely at intervals during chemotherapy. The regularity and type of blood test done depends on the patient, the combination of drugs used and the side effects experienced.

Thankfully, like all drugs (including Panado and Aspirin), not every side effect is experienced by every person, and some side effects are experienced to lesser degrees in some people. many of the side effects may be unpleasant, but may not be harmful.

 

The good news is that cancer cells divide more rapidly than normal cells and therefore more likely to be killed by chemotherapy.

More good news is that normal cells are also more able to recover than cancer cells and therefore most side effects are not permanent and will reverse once the treatment is finished.

 

If you have any problems with side effects, be sure to tell your doctor or nurse because there are often ways to help.

 

Frequently asked questions around chemotherapy:

 

"If I need chemo, when do I have to start?":

Within 4-6 weeks of your definitive operation. Any later than that, and research has shown you may be compromising the efficacy of the treatment.

 

"But I have had some post-operative complications and I am not fully healed yet. Shouldn't I wait?":

No. Not even if you have an open wound. You need to start your chemo on time. An open wound can be kept covered and infection free during chemo, and can be sorted out after chemotherapy. This does not impact on the cosmetic result. Skin grafts and other procedures are not recommended during chemo. Wait until afterwards.

 

"So just how bad am I going to feel?":

This is impossible to predict. Everybody is different. Many people can continue working during chemo, but may find they need to take a day or 2 off after chemo before going back to work. Remember your experience will be different from the lady sitting next to you in the chemo room, so don't panic if you find you are having a harder time than she (or an easier time!). Tell your doctor. Often something can be done to make the next time better. Something's you may have to grin and bear.

 

"What about other medicines, drugs and supplements?":

It is important to discuss this with your specialist any drugs you are taking or additional drugs you would like to take. This includes vitamins or dietry supplements, vaccines or immunizations, immune boosters and herbal medicines. They may interfere with the affectivity of your chemotherapy treatment.

ENDOCRINE / HORMONE

THERAPY

Some breast cancer cells have receptors which allow oestrogen and progesterone hormones to attach to the cells and stimulate them to divide and grow. These cancers are then described as being oestrogen and/or progesterone positive. Endocrine (hormonal) therapy may then be advised as part of the cancer treatment. Examples of endocrine treatment include Tamoxifen or Aromatase inhibitors which are given in the form of a tablet each day for 5 to 20 years and prevents oestrogen from having a stimulating effect on the cancer cells. Other types of endocrine therapies are also available, some of which are injectables.

 

Side effects:

Side effects from endocrine treatment are very manageable:

 

TAMOXIFEN: most side effects do not occur immediately but rather some time after treatment has been started. Being an "anti-hormone" some of these side effects may include: hot flushes, vaginal discharge or dry vagina, weight gain, mood changes and decreased libido (sex drive). Other important side effects of tamoxifen include: increased risk of blood clots particularly deep venous thrombosis (DVT) and thickening of the lining of the uterus which may lead to an increase incidence of edometrial cancer (women on tamoxifen should therefore have a yearly gynaecological check up and ultrasound scan of the uterus).

 

AROMATASE INHIBITORS: the "hormonal" side effects are similar to Tamoxifen: hot flushes, vaginal discharge or dry vagina, weight gain, mood changes and decreased libido (sex drive). In addition, some patients may experience muscle or joint aches. Osteoporosis and osteopaenia (thinning of the bones) may occur and it is therefore important for patients to take supplementary calcium and Vitamin D and have a baseline Bone Mineral Density Scan done when starting the treatment and yearly while taking it.

TARGETED

THERAPY

Targeted cancer therapies are treatments that target specific characteristics of cancer cells and are therefore less likely to harm normal, healthy cells. Examples currently available include Trastuzumab (Herceptin), Lapatinib (Tykerb), Pertuzumab (Perjeta).

 

In about 15% of breast cancers, the cancer cells have a gene mutation that makes an excess of protein called HER2 (Human Epidermal Growth Factor Receptor 2) which promotes the growth of these cancer cells. HER2-positive breast cancers tend to be more aggressive than other types of breast cancer but the good news is that the HER2 receptor can be targeted by a drug called Herceptin.

Herceptin works by attaching itself to the HER2 receptors on the breast cancer cells and blocking them from receiving growth signals. Treatments that specifically target HER2 are so effective that the prognosis for HER2-positive breast cancer is now actually quite good. Herceptin can be used to treat early breast cancer as well as metastatic breast cancer. It is given intravenously and usually in combination with chemotherapy.

 

Side effects:

Side effects are few due to the fact that the treatment targets the cancer cells and spares the normal cells. 40% of people may complain of transient flu-like symptoms such as fever, muscle aches, nausea and fatigue.

Less commonly, Herceptin can damage the heart and result in symptoms such as shortness of breath and swelling of the legs. The risk of heart damage is greater in patients who have had pre-existing heart problems, older patients, and when Herceptin is given along with other chemotherapy medicines known to cause heart damage.

MOVING ON

AFTER TREATMENT

Although it is a relief to have completed treatment, it can be a stressful time as it is hard not to worry about the cancer coming back. Recurrence of cancer is a common concern amongst cancer survivors and it may take a while before your confidence in your recovery begins to feel real.

 

Follow up care

It is important and you are encouraged to keep all your follow up appointments. These visits are an opportunity to talk about symptoms and for your doctor to do a physical examination. Laboratory or imaging tests may be considered at these visits. The longer you are free of cancer, the less often you will need visits.

 

Lymphoedema

This can occur any time after treatment for breast cancer - right after surgery or months or even years later.

Lymphoedema is swelling (usually of the arm in the case of breast surgery and/or radiation) caused by disruption to the lymphatic drainage system leading to lymphatic fluid build up.

Lymphoedema is treatable but not curable, so is best prevented or at least diagnosed as early as possible and kept under control.

Tell your doctor right away about any swelling, tightness or injury to the hand or arm.

Lymphoedema should ideally be treated by a trained Lymphoedema therapist (usually a physiotherapist, occupational therapist or nurse) working together with the patient ant the family. Preventative strategies include using gloves when gardening and avoiding having intravenous drips, blood drawn from or blood pressure taken on the arm on the side of the lymph node surgery or radiation.

Contact CANSA toll-free 0800226622 for information about Lymphoedema clinics near you.

 

Quality of Life

Women who have had treatment for breast cancer should know that they can have a normal quality of life after treatment is over.

 

Emotional aspects of breast cancer

Once your treatment ends, you may find that you are overwhelmed by emotions. This happens to a lot of women. This is an ideal time to seek out support if you have not already done so during your treatment. Support can come in many forms: family, friends, cancer support groups, church or other spiritual groups. You don't have to walk the journey alone. If you are not sure who to contact for help, contact CANSA....................... and they can put you in touch with a group.

 

Making healthier choices

Think about your lifestyle before you were diagnosed with cancer. What were the healthy things that you did, and what were the things that you did that might have made you less healthy? Think about diet, smoking, stress management and alcohol intake.

You can start making changes today that can have positive effects for the rest of your life. Not only will you feel better, but you will also be healthier.

 

Diet and Nutrition

One of the best things you can do after treatment is to put healthy eating habits into place. You will be surprised at the long-term benefits of some simple changes, like increasing the variety of healthy foods that you eat. Try to eat 5 servings of vegetables and fruits each day. Choose whole grains instead of white flour and sugars. Try to limit meats that are high in fat. Cut back on processed foods. If you drink alcohol, limit yourself to 1 drink a day at the most. And get regular exercise. The combination of a balanced diet and exercise will keep you feeling more energetic and help you maintain a healthy weight which will reduce your risk of the cancer coming back.

 

Sexual Health

This is probably the least talked about aspect of your life that is affected after a diagnosis of breast cancer.

Physical changes after surgery may make some women feel uncomfortable about their bodies. There may be decreased breast sensation or the breasts may be hypersensitive.

Treatments like chemotherapy and hormone therapy can change your hormone levels and affect your sexual interest or response. You may have symptoms of menopause like hot flushes, vaginal dryness and menstrual cycle changes. In spite of these changes you should still be able to have meaningful sex and reach orgasm. Vaginal dryness can be improved with various creams or lotions. Your partner may also feel unsure how to express love emotionally and physically which can lead to tension in relationships.

Breast cancer can be a positive growth experience for couples when partners acknowledge potential problems, are more aware of what to expect and engage actively in seeking advice.

CONTACT INFO

TEL: 021 531 6924

FAX: 021 531 7997

EMAIL: admin@capebreastcare.org

BREAST DISEASES CLINIC

DRS GUDGEON AND BOEDDINGHAUS ASSOCIATION

CLINICAL

INFORMATION

BREAST

AWARENESS

We encourage all women to be aware of how their breasts look and feel normally and report any changes to their doctor. Finding a change does not mean that you have cancer.

By being aware of how your own breasts look and feel, you will be more likely to notice any changes that might take place. You can also choose to use a step by step approach to checking your breasts on a set schedule.

The best time to do a breast self-examination (BSE) is when your breasts are not tender or swollen, so avoid the days just before your period or during your period.

Look for these changes: a lump or swelling, skin dimpling, nipple turning inward, redness or scaling of the nipple or breast skin, a discharge from the nipple other than breast milk, a lump under the arm.

Remember- most of the time these breast changes are not cancer.

BREAST CANCER

SCREENING

 

DIAGNOSIS

BENIGN

BREAST LUMPS

BREAST

CANCER

RISK

FACTORS

BREAST CANCER

TERMINOLOGIES

MOVING ON

AFTER TREATMENT

CLINICAL

INFORMATION

BREAST

AWARENESS

We encourage all women to be aware of how their breasts look and feel normally and report any changes to their doctor. Finding a change does not mean that you have cancer.

By being aware of how your own breasts look and feel, you will be more likely to notice any changes that might take place. You can also choose to use a step by step approach to checking your breasts on a set schedule.

The best time to do a breast self-examination (BSE) is when your breasts are not tender or swollen, so avoid the days just before your period or during your period.

Look for these changes: a lump or swelling, skin dimpling, nipple turning inward, redness or scaling of the nipple or breast skin, a discharge from the nipple other than breast milk, a lump under the arm.

Remember- most of the time these breast changes are not cancer.

BREAST CANCER

SCREENING

The term screening refers to tests and examinations used to find a disease like cancer in people who do not have any symptoms or signs or who have not noticed any breast changes. The earlier a breast cancer is found, the better the cancer's treatment will work and therefore the better the outcomes. The goal of screening is to find the cancer before it starts to cause symptoms. Most doctors feel that early detection tests for breast cancer save many thousands of lives each year. The guidelines for screening differ in different countries but generally include the following:

 

Mammogram: Women over 40 should ask their doctor how often to go for a mammogram. While mammograms can miss some cancers, they are still a very good way to find breast cancer including the "in situ" cancers ie: cancers that are not yet invasive. A mammogram is an X-ray of the breast. Very low levels of radiation are used. The breast is flattened between 2 Xray plates and, although this may be uncomfortable, it only lasts a few moments and is required to get a good picture.

 

Clinical breast examination (CBE): Women in their 20's and 30's should have CBE as part of their regular examination by a health expert at least every 3 years. After age 40, women should have a CBE every year.

 

Breast self-examination (BSE): BSE is an option for women starting in their 20's. Women should be told about the benefits and limitations of BSE. If you do a BSE on a regular basis, you get to know how your breast normally look and feel and can more easily notice changes. Any worrying changes should be reported to your health professional.

 

Women at high risk: Women who have a higher risk of breast cancer should discuss with their doctor the best approach for them. This may mean starting mammograms when they are younger, having extra screening tests or more frequent examinations.

 

DIAGNOSIS

If  you discover a breast lump or breast change, an appointment should be made with your doctor or nurse for a clinical assessment.

They will advise whether further tests are needed.

Three approaches are usually involved in investigating breast diseases:

 

1. A physical examination:

 The examiner will first look at your breast for changes in size or shape.

 Then using the pads of the fingers he/she will gently feel your breasts for

 lumps.  The area under your arms will also be checked.

 

2. Imaging:

 

 Mammogram: This is usually the first imaging examination that is

performed in women over 40 years of age.  It is an x-ray of the breast.  Very low levels of radiation are used.  The breast is pressed between two plates to flatten and spread the tissue. The pressure may cause some discomfort during the short while it takes to take the X-Ray.

 

Ultrasound: In women younger than 30 years or depending on the results of the  mammogram in an older woman, an ultrasound may be requested.  The ultrasound uses  high frequency sound waves to obtain images.

 

Magnetic Resonance Imaging (MRI): The MRI is of limited use in breast screening but  may be indicated in woman who have a genetic mutation and are at extremely high risk for  breast cancer.

 

3. Biopsy:

 

The Fine Needle Aspiration Biopsy (FNA or FNAB):

This is the least invasive biopsy method.  Small amounts of cells are aspirated (sucked up)  into a syringe through a needle: a bit like a blood test.  No stitches are needed.  The  procedure can be performed in your Doctor’s office and takes only a few minutes. Results  are usually available later the same day or within 24 hours.

 

Core biopsy:

This can also be performed in your Doctor’s office but requires a local anaesthetic to numb  the area.  These core biopsies provide a larger tissue sample but may not be suitable for  patients with a very small or hard lump.

 

Biopsies could also be conducted under ultrasound guidance or stereotactic (mammographic) guidance if the area of abnormality is not in the form of an “easy-to-feel” lump.

 

 

BENIGN

BREAST LUMPS

Most breast lumps are benign which means they are not cancers. They do not spread outside of the breast and they are not life threatening. But some benign breast lumps can increase a woman's chance of getting breast cancer.

 

So, if a breast lump is not a cancer, what could it be?

 

Fibroadenomas: solid, smooth, rubbery lumps that move around easily in the breast tissue. They consist of fibrous (or connective) tissue and normal glandular tissue of the breast.

 

Lipomas: benign growths of fat cells.

 

Cysts: small sacs of fluid within the breast tissue.

 

Fibrocystic change: small fluid filled sacs called "cysts" become entrapped in dense fibrous tissue within the breast. May present as breast lumpiness, thickening, and/or swelling which may be tender or painful.

 

It is important that all breast lumps are investigated fully before diagnosis is made.

BREAST

CANCER

Symptoms and Signs:

 

The widespread use of screening mammograms has increased the number of breast cancer found before they cause any symptoms.

 

The most common sign is a breast lump. A lump that is painless, hard, and has uneven edges is more likely to be cancer. However some cancers are tender, soft and smooth. So it's important to have any lump or breast change checked by a doctor.

 

Other signs that could sometimes suggest breast cancer are:

 

  • Swelling or change in size of the breast.
  • Skin irritation or dimpling.
  • Nipple change - pain or retraction (pulling inwards).
  • Rash, redness, scaling or thickening on or around the nipple or breast skin.
  • Nipple discharge.
  • Lump under the arm.

 

What causes breast cancer?

Certain changes in DNA can cause normal breast cells to become cancerous. DNA makes up our genes which code for the instructions for how our cells work. Some inherited DNA changes can increase the risk for developing cancer are responsible for cancers that run in some families.

RISK

FACTORS

Certain risk factors are linked to the disease.

A risk factor is anything that increases a person's chance of getting a disease such as cancer. Some risk factors are linked to a persons lifestyle choices and can be changed, such as smoking, drinking of alcohol and diet.

Other risk factors such as a person's age or family history cannot be changed.

Having a risk factor, or even a gene, does not mean that you will definitely get the disease. Some women who have one or more risk factors never get the breast cancer, and many women who develop breast cancer don't have any risk factors.

While all women are at risk for breast cancer the factors below may increase a woman's chances of developing the disease.

 

Risk Factors you cannot change:

 

Gender:

Simply being a woman increases the risk of developing breast cancer over a man's. While men also get breast cancer, it is 100 times more common in women that in men.

 

Age:

This is the strongest risk factor for developing breast breast cancer. The chance of getting breast cancer increases as a women gets older. About 2 out of 3 women with invasive breast cancer are age 55 or older when cancer is found.

 

Personal History of breast cancer:

A woman with cancer in one breast has a greater chance of getting a new cancer in the other breast or in another part of the same breast. This is different from a return of the first cancer (which is called recurrence).

 

Family History:

Breast cancer risk is higher among women whose close blood relatives have this disease. The relatives can be from either the mother's or father's side of the family. The more family members affected, the younger they were at diagnosis and the closer they are related: the higher the chance of breast cancer in that individual.

 

Genetic:

Breast cancers linked to positive genes make up the minority (5-10%) of breast cancer cases. The most common gene changes that have been identified as being linked with breast cancer are those of the BRCA1 and BRCA2 mutations. Women with these gene changes have an increased risk of getting breast cancer during their lifetimes.

 

There are tests that can tell if a woman has certain changed (mutated) genes linked to breast cancer. With this information, women can then take steps to reduce their risks. If you are thinking about genetic testing, you should talk to a genetic counselor, nurse or doctor qualified to explain the nature and possible outcomes of these tests. It is very important that you know what genetic testing can and can't tell you, and to carefully weigh the benefits and risks of testing before these tests are done.

 

Dense breast tissue:

Dense breast tissue means there is more glandular tissue and less fatty tissue. Women with denser breast tissue have a higher risk of breast cancer. Dense breast tissue can also make the breast tissue can also make the breast more difficult to examine and more difficult for doctors to identify problems on mammograms.

 

Menstrual periods:

Women who began having periods early (before age 11) or who went through the change of life (menopause) after the age of 55 have a slightly increased risk of breast cancer.

 

Risk Factors influenced by lifestyle choices.

 

Not having children or having them later in life:

Women who have not had children, or who had their first child after age 30, have slightly higher risk of breast cancer.

 

Use of birth control pills:

Studies have found that women who are using birth control pills have a slightly greater risk of breast cancer (however, also a lower risk of ovarian cancer!) than women who have never used them. Women who stopped using the pill more than 10 years ago do not seem to have any increased risk. It's a good idea to talk to your doctor about the risks and benefits of birth control pills.

 

Hormone replacement therapy (HRT):

Has been used for many years to help relieve symptoms of menopause and to help prevent thinning of the bones (osteoporosis). It has become clear that long-term use (several years or more) of the combined forms of HRT increases the risk of breast cancer. There are some good reasons to use HRT other than for short-term relief of menopausal symptoms. Because there are other factors to think about, women should talk  with their doctors about the advantages and disadvantages of using HRT. If a woman and her doctor have decided to try HRT purely for relief of menopausal symptoms, it is usually best to use it at the lowest effective dose and the shortest time possible.

 

Not breast-feeding:

Some studies have shown that breast-feeding slightly lowers breast cancer risk, especially if the total combined time of breast-feeding lasts at least a year or 2.

 

Alcohol:

Use of alcohol is clearly linked to an increased risk of getting breast cancer. Try to limit the amount to one drink a day, if at all.

 

Being overweight or obese:

Being overweight or obese is linked to a higher risk of breast cancer, especially for women after menopause if the weight gain took place during adulthood. Also the risk seems to be higher if the extra fat is in the waist area. The link between weight and breast cancer is complex. It is recommended to maintain a healthy weight throughput life.

 

Lack of exercise:

Studies show that exercise reduces breast cancer risk. This may be because exercise helps control weight. The only question is how much exercise is needed.

 

High fat diets:

Studies found that breast cancer is less common in countries where the typical diet is low in fat. Eating a healthy, low fat diet that includes 5 or more servings of vegetables and fruits each day, choosing wholegrain products instead of refined starches, and limiting the amount of processed and red meats is recommended.

 

Tobacco smoke:

A possible link to breast cancer is another reason to stop smoking and avoid being around secondhand smoke.

Many of us can make some adjustments to our lifestyle choices which may lower our risk of getting breast cancer.

For more information about risk factors for breast cancer go to:

https://www.cancer.org/cancer/breast-cancer/risk-and-prevention.html

 

What if you are at increased risk?

There are some things you can do to reduce your chances of getting breast cancer if you are at an extremely increased risk based on your family history or genetics. This could include chemoprevention or preventive surgery. Before deciding which, if any, of these may be right for you, talk with your doctor.

Chemoprevention:

Chemoprevention is the use of drugs to reduce the risk of cancer. Many drugs have been studied for use in lowering breast cancer risk.

Preventative surgery for women with very high breast cancer risk:

For the few women who have a very high risk for breast cancer, preventative surgery such as bilateral (double) mastectomy, or oophorectomy (removal of the ovaries) may be an option. The reasons for thinking about this type of surgery need to be very strong. There is no way to know ahead of time whether this surgery will benefit a particular woman. A second opinion is strongly recommended before making a decision to have this type of surgery.

BREAST CANCER

TERMINOLOGIES

Breast tissue that has been removed by biopsy is sent to the pathology laboratory for analysis: A description of the cells may involve the following terms:

 

Benign:

Benign tumors are not cancerous. Some may grow or increase in size, but they do not spread outside the breast and are not life threatening.

 

Malignant:

Malignant tumors are what are referred to as breast cancer. Cells of malignant tumors have the potential to break off from the main tumor or cancer. From there they can spread to the lymph nodes via the lymphatic ducts, or to more distant organs via the blood stream.

 

It can be hard to understand some of the words you come across when talking or reading about breast cancer.

There are many kinds of breast cancer. They are described in terms of their type, their grade and their receptor status. Different kinds of breast cancers behave differently and will respond to different treatments than others. This is important in guiding the treating team in selecting the most appropriate therapies for each individual patient.

TYPES OF

BREAST CANCER

Carcinoma: a cancer that begins in the lining of the breast ducts (Ductal Carcinoma) or lobules (Lobular Carcinoma).

 

Adenocarcinoma: a cancer that starts in glandular tissue (tissue that makes or secretes a substance). The ducts and lobules of the breast are glandular tissue (they make breast milk), so cancers that start in these areas are sometimes adenocarcinomas.

 

Carcinoma in situ: this term is used to describe the earliest stage of breast cancer, when it is still only in the layer of cells where it began. In breast cancer, "in situ" means that the cancer cells are still only in the ducts (ductal carcinoma in situ - DCIS) or in the lobules (lobular carcinoma in situ - LCIS). The cancer cells have not yet invaded the breast tissue. They are sometimes referred to as non-invasive breast cancer.

 

Invasive (or Infiltrating) Carcinoma: An invasive cancer is one that has grown beyond the layer of cells where it started (unlike carcinoma in situ). Most breast cancers are invasive carcinomas - either invasive ductal carcinomas or invasive lobular carcinomas.

 

Sarcomas: These are cancers that start from connective tissue like muscle, fat or blood vessels. Sarcomas of the breast are rare. Sometimes a breast tumor can be a mix of these types or a mixture of invasive and in situ cancer.

 

Sometimes a breast tumor can be a mix of these types or a mixture of invasive and in situ cancer.

STAGES OF

BREAST CANCER

Breast tumors are often described by stage. Staging takes into account the size of the tumor, where there are any lymph nodes involved, and whether it has spread far from its original site or metastasised. It is an induction of the distance it has spread and not necessarily how that tumor will behave.

 

Breast cancer cells could spread through either the lymphatics (to the lymph nodes) or the bloodstream to other parts of the body via the bloodstream such as the bones, lungs and liver.

Simplified stages of breast cancer are:

 

Stage 0: non invasive (in situ).

 

Stage 1: invasive but less than 2cm in size and no lymph nodes involved.

 

Stage 2: invasive with asize of 2-5cm, or smaller but spread to a few lymph nodes in the armpit.

 

Stage 3: size more than 5cm, or smaller but spread to many lymph nodes which become stuck to one another or has spread to the breast skin, chest wall or internal mammary lymph nodes.

 

Stage 4: spread to more distant organs.

GRADES OF

BREAST CANCER

Grading of a Breast Cancer is based on the microscopic appearance of the tumor cells and give an indication of the rate (speed) of growth.

Simplified grades of breast cancer:

 

Grade 1: cells look relatively normal = well defined, slow growing.

 

Grade 2: characteristics between Grade 1 and 3 = moderately differentiated.

 

Grade 3: cells lack normal features = poorly differentiated - tend to grow much quicker.

 

The grade of a tumor is related to prognosis. The grade 1 or low grade tumor has a better prognosis because it grows more slowly and tends to spread later than higher grade tumors.

BREAST CANCER

RECEPTORS

Some breast cancer cells have high numbers of receptors for some hormones or growth factors which can influence their growth. The laboratory can do tests for these on the tissue sample from the biopsy.

Hormone receptor positive:

If there are high numbers of oestrogen receptors (ER) or progesterone receptors (PR) reported on the pathology report, the cancer will be called ER or PR positive. This is important to know in order to plan treatment, as hormone receptor positive breast cancers will respond well to anti-hormonal treatment (such as Tamoxifen or Aromatase Inhibitors).

 

HER2 receptor positive:

If there are high numbers of receptors to the human epidermal growth factor receptor 2, the cancer will be called HER2 positive. HER2 positive tumors tend to be fast growing. They also respond to the HER2 targeted therapy called Herceptin.

TREATMENT OF

BREAST CANCER

Treatment of breast cancer is individualised according to the type, grade, stage and receptor status of the cancer and also the age and health status of the patient. Therefore advised treatment plans may differ between patients. General types of treatment can be put into broad groups, based on how they work and when they are used. Combinations of the various treatments are often advised for individual patients with breast cancer.

LOCAL VS SYSTEMIC

TREATMENT

The purpose of local treatment is to treat a tumor without affecting the rest of the body. Surgery and radiation are examples of local treatment.

 

Systemic treatment is given into the bloodstream or by mouth to go throughout the body and reach cancer cells that may have spread beyond the breast.

Chemotherapy, hormone therapy, immunotherapy and biologial therapy are systemic treatments.

ADJUVANT VS NEO-ADJUVANT

TREATMENT

Cancer cells may break away from the main tumour and spread through the bloodstream even in the early stages of the disease. It is very hard to tell if this has happenend. But, if it has, theses cellss can start new tumours in other organs months or years later. Therefore a patient, depending on the type, stage, grade and receptor status of the cancer, may be advised to have certain treatements after their surgery in order to kill these hidden cells. This is called Adjuvant therapy.

 

Neo-adjuvant therapy is when patients have systemic therapy BEFORE their surgery either to shrink a cancer before the operation, or if the operation needs to be delayed for some reason.

 

SURGERY

Most women with breast cancer will have some type of surgery to treat the main breast tumor. The purpose of surgery is to remove as much of the cancer as possible. Surgery can also be done to find out whether the cancer has spread to the lymph nodes under the arm (sentinel lymph node biopsy). Plastic and Reconstructive or cosmetic surgery can be done to improve the breasts appearance after the surgery.

 

Breast Conserving Surgery: Lumpectomy (Wide Local Excision) and Partial mastectomy are examples of breast conserving surgery. In these types of surgery, only part of the breast is removed and needs to be followed by radiation therapy:

 

Lumpectomy or Wide Local Excision: this surgery involves removing only the breast lump and a margin of normal tissue around it. Radiation treatment is usually given after this type of surgery. If chemotherapy is also going to be used, the radiation may be delayed until the chemo is finished.

 

Partial Mastectomy: this surgery involves removing more of the breast tissue than in a wide local excision. It is usually followed by radiation therapy.

 

Mastectomy: Mastectomy involves removal of the whole breast.

 

Reconstructive surgery: these operations do not treat the cancer, but can be done to restore the way the breast looks after the cancer has been surgically removed. There are several choices about what type of reconstruction can be done and whether it is done at the time of the cancer surgery, or delayed until after all treatment. This should be discussed with your surgeon and a plastic surgeon before the cancer surgery is performed.

 

Complications of surgery: possible surgical complications can include bleeding, pain, infection, temporary swelling, seroma (pocket of clear or bloodstained fluid collecting at incision site), shoulder stiffness, numbness, thickened tissue due to scar tissue that forms at the surgical site. Complications are more common in smokers, diabetics, older patients and those who have had previous radiotherapy.

The simpler the surgery, the less likely the complications.

 

Lymphoedema is an important complication:

If lymph nodes are removed from under the arm, lymphoedema may occur. Lymphoedema is swelling (usually of the arm in the case of breast surgery and/or radiation) caused by disruption to the lymphatic drainage system leading to lymphatic fluid build up. It can occur any time after treatment for breast cancer - right after surgery, months or even years later. Lymphoedema is treatable but not curable, so is best prevented or at least diagnosed as early as possible and kept under control. Injury or infection of the arm on the affected can cause lymphoedema or make it worse. Tell your doctor right away about any swelling, tightness or injury to the hand or arm. Lymphoedema should ideally be treated by a trained Lymphoedema therapist (usually a physiotherapist, occupational therapist or nurse) working together with the patient and the family. Most of the time, there is some improvement. If the Lymphoedema has been there for a long time, there are changes to the soft tissues in the arm which may not be reversible. As a result the arm may be permanently swollen. Therefore, it is important to start management for lymphoedema early to try and prevent a chronic problem. Preventative strategies include using gloves when gardening and avoiding having intravenous drips, blood drawn from or blood pressure taken on the arm on the side of the lymph node surgery or radiation.

Contact CANSA toll-free 0800226622 for information about lymphoedema clinics near you.

 

RADIOTHERAPY

RADIOTHERAPY: (also called radiation therapy, or radiation oncology) is the medical use of ionising radiation or high energy rays to damage cancer cells and stop them growing and dividing. Like surgery it is a highly targeted local treatment which affects cancer cells only in the treated area.

 

Radiotherapy for breast cancer can be used:

 

  • after lumpectomy or mastectomy, either alone or in combination with chemotherapy and/or hormone therapy.
  • as the main treatment if the tumor cannot be safely surgically removed or the person's health does not allow for surgery.
  • to treat the bones or the brain if the cancer has spread there.
  • to relieve pain, or assist in reducing the leaking or bleeding of open wounds of locally advanced cancer.

 

Side effects/complications:

These depend on the treatment dose and the part of the body that is treated:

The most common side effects are tiredness, loss of appetite, breast swelling/tenderness, skin rash/redness or hair loss in the treated area. Some patients may find the breast skin more sensitive after radiation while others may find it less sensitive. Some skin changes can look similar tot he changes seen in breast cancer.

Most of the side effects are not acute, and because the patient is usually being seen every day by the treatment team, they can be effectively managed.

For more information and tips on how to manage side effects please go to__________

 

Lymphoedema: as with surgery, radiotherapy may increase a patient's risk of developing Lymphoedema (swelling) of the arm. The risk is higher for patients who have had radiotherapy as well as having had auxiliary lymph nodes removed.

 

CHEMOTHERAPY

Chemotherapy drugs are used to kill cancer cells throughout the body. They work by disrupting the mechanics of cell division. Cancer cells are known to divide and replicate and grow much faster than normal cells and are therefore more susceptible to chemotherapy drugs. Many different types of chemotherapy drugs are used to treat different cancers and each drug works at a slightly different part of the cell division process. The treatment may include more than one drug and this is called combination therapy. A combination of drugs with different actions may work together to kill more cancer cells and reduce the chance that the cancer may become resistant to any one particular drug.

 

They are usually given by through an intravenous drip (or, in some cases, tablets by mouth) with the aim of travelling through the bloodstream to reach more distant parts of the body. Chemotherapy is normally given in an outpatient clinic so patients can go home the same day.

 

Chemotherapy can be given in different situations which will vary according to each individual patient's situation:

 

  1. ADJUVANT CHEMOTHERAPY: (Treatment after surgery):                                                                                                        There is the possibility that, before the time of surgery, a few cancer cells may have broken away from the main tumor and spread through the bloodstream to settle in other places such as lymph nodes, bone liver, brain or lungs. These may start growing and cause problems sometimes many years after initial treatment. The aims of adjuvant treatment is to kill these hidden cells and reduce the risk of future recurrence. Not every patient needs adjuvant chemotherapy as some patients are not a high risk of this happening, and some breast cancer types do not succumb to chemotherapy as much as others.
  2. NEO-ADJUVANT: (Treatment before surgery):                                                                                                                            The main benefit of this is to shrink large cancers so that they are small enough to be removed safely or to improve cosmetic outcome. Another advantage is that doors can monitor how the cancer responds during chemotherapy.
  3. ADVANCED METASTATIC CANCER:                                                                                                                                 Chemotherapy can also be used as the main treatment for cancer that have already spread outside the breast and armpit at the time it is found, or if it spreads after the first treatments.

 

Possible Side Effects:

Chemotherapy drugs cannot distinguish between cancer cells and normal cells and may therefore affect some normal rapidly dividing cells in the body such as hair, skin, nails, lining of the digestive system and bone marrow (blood cell lines).

Therefore there are various side effects associated with the therapy and because each drug acts in a slightly different way, the side effects will also differ between the drugs.

 

Some side effects include: tiredness/fatigue (caused by low red blood cells) - anaemia, higher risk of infection (caused by low white blood cells) - neutropaenia, easier bruising/bleeding (caused by low platelet counts), hair loss, mouth sores, skin/nail changes, nausea / vomiting / diarrhoea / constipation, loss of appetite, peripheral neuropathy, changes in menstrual cycle and fertility.

 

Please go to ______________for more information on side effects, how to manage them and when to contact your doctor.

 

Blood cell counts are tested routinely at intervals during chemotherapy. The regularity and type of blood test done depends on the patient, the combination of drugs used and the side effects experienced.

Thankfully, like all drugs (including Panado and Aspirin), not every side effect is experienced by every person, and some side effects are experienced to lesser degrees in some people. many of the side effects may be unpleasant, but may not be harmful.

 

The good news is that cancer cells divide more rapidly than normal cells and therefore more likely to be killed by chemotherapy.

More good news is that normal cells are also more able to recover than cancer cells and therefore most side effects are not permanent and will reverse once the treatment is finished.

 

If you have any problems with side effects, be sure to tell your doctor or nurse because there are often ways to help.

 

Frequently asked questions around chemotherapy:

 

"If I need chemo, when do I have to start?":

Within 4-6 weeks of your definitive operation. Any later than that, and research has shown you may be compromising the efficacy of the treatment.

 

"But I have had some post-operative complications and I am not fully healed yet. Shouldn't I wait?":

No. Not even if you have an open wound. You need to start your chemo on time. An open wound can be kept covered and infection free during chemo, and can be sorted out after chemotherapy. This does not impact on the cosmetic result. Skin grafts and other procedures are not recommended during chemo. Wait until afterwards.

 

"So just how bad am I going to feel?":

This is impossible to predict. Everybody is different. Many people can continue working during chemo, but may find they need to take a day or 2 off after chemo before going back to work. Remember your experience will be different from the lady sitting next to you in the chemo room, so don't panic if you find you are having a harder time than she (or an easier time!). Tell your doctor. Often something can be done to make the next time better. Something's you may have to grin and bear.

 

"What about other medicines, drugs and supplements?":

It is important to discuss this with your specialist any drugs you are taking or additional drugs you would like to take. This includes vitamins or dietry supplements, vaccines or immunizations, immune boosters and herbal medicines. They may interfere with the affectivity of your chemotherapy treatment.

ENDOCRINE / HORMONE

THERAPY

Some breast cancer cells have receptors which allow oestrogen and progesterone hormones to attach to the cells and stimulate them to divide and grow. These cancers are then described as being oestrogen and/or progesterone positive. Endocrine (hormonal) therapy may then be advised as part of the cancer treatment. Examples of endocrine treatment include Tamoxifen or Aromatase inhibitors which are given in the form of a tablet each day for 5 to 20 years and prevents oestrogen from having a stimulating effect on the cancer cells. Other types of endocrine therapies are also available, some of which are injectables.

 

Side effects:

Side effects from endocrine treatment are very manageable:

 

TAMOXIFEN: most side effects do not occur immediately but rather some time after treatment has been started. Being an "anti-hormone" some of these side effects may include: hot flushes, vaginal discharge or dry vagina, weight gain, mood changes and decreased libido (sex drive). Other important side effects of tamoxifen include: increased risk of blood clots particularly deep venous thrombosis (DVT) and thickening of the lining of the uterus which may lead to an increase incidence of edometrial cancer (women on tamoxifen should therefore have a yearly gynaecological check up and ultrasound scan of the uterus).

 

AROMATASE INHIBITORS: the "hormonal" side effects are similar to Tamoxifen: hot flushes, vaginal discharge or dry vagina, weight gain, mood changes and decreased libido (sex drive). In addition, some patients may experience muscle or joint aches. Osteoporosis and osteopaenia (thinning of the bones) may occur and it is therefore important for patients to take supplementary calcium and Vitamin D and have a baseline Bone Mineral Density Scan done when starting the treatment and yearly while taking it.

TARGETED

THERAPY

Targeted cancer therapies are treatments that target specific characteristics of cancer cells and are therefore less likely to harm normal, healthy cells. Examples currently available include Trastuzumab (Herceptin), Lapatinib (Tykerb), Pertuzumab (Perjeta).

 

In about 15% of breast cancers, the cancer cells have a gene mutation that makes an excess of protein called HER2 (Human Epidermal Growth Factor Receptor 2) which promotes the growth of these cancer cells. HER2-positive breast cancers tend to be more aggressive than other types of breast cancer but the good news is that the HER2 receptor can be targeted by a drug called Herceptin.

Herceptin works by attaching itself to the HER2 receptors on the breast cancer cells and blocking them from receiving growth signals. Treatments that specifically target HER2 are so effective that the prognosis for HER2-positive breast cancer is now actually quite good. Herceptin can be used to treat early breast cancer as well as metastatic breast cancer. It is given intravenously and usually in combination with chemotherapy.

 

Side effects:

Side effects are few due to the fact that the treatment targets the cancer cells and spares the normal cells. 40% of people may complain of transient flu-like symptoms such as fever, muscle aches, nausea and fatigue.

Less commonly, Herceptin can damage the heart and result in symptoms such as shortness of breath and swelling of the legs. The risk of heart damage is greater in patients who have had pre-existing heart problems, older patients, and when Herceptin is given along with other chemotherapy medicines known to cause heart damage.

MOVING ON

AFTER TREATMENT

Although it is a relief to have completed treatment, it can be a stressful time as it is hard not to worry about the cancer coming back. Recurrence of cancer is a common concern amongst cancer survivors and it may take a while before your confidence in your recovery begins to feel real.

 

Follow up care

It is important and you are encouraged to keep all your follow up appointments. These visits are an opportunity to talk about symptoms and for your doctor to do a physical examination. Laboratory or imaging tests may be considered at these visits. The longer you are free of cancer, the less often you will need visits.

 

Lymphoedema

This can occur any time after treatment for breast cancer - right after surgery or months or even years later.

Lymphoedema is swelling (usually of the arm in the case of breast surgery and/or radiation) caused by disruption to the lymphatic drainage system leading to lymphatic fluid build up.

Lymphoedema is treatable but not curable, so is best prevented or at least diagnosed as early as possible and kept under control.

Tell your doctor right away about any swelling, tightness or injury to the hand or arm.

Lymphoedema should ideally be treated by a trained Lymphoedema therapist (usually a physiotherapist, occupational therapist or nurse) working together with the patient ant the family. Preventative strategies include using gloves when gardening and avoiding having intravenous drips, blood drawn from or blood pressure taken on the arm on the side of the lymph node surgery or radiation.

Contact CANSA toll-free 0800226622 for information about Lymphoedema clinics near you.

 

Quality of Life

Women who have had treatment for breast cancer should know that they can have a normal quality of life after treatment is over.

 

Emotional aspects of breast cancer

Once your treatment ends, you may find that you are overwhelmed by emotions. This happens to a lot of women. This is an ideal time to seek out support if you have not already done so during your treatment. Support can come in many forms: family, friends, cancer support groups, church or other spiritual groups. You don't have to walk the journey alone. If you are not sure who to contact for help, contact CANSA....................... and they can put you in touch with a group.

 

Making healthier choices

Think about your lifestyle before you were diagnosed with cancer. What were the healthy things that you did, and what were the things that you did that might have made you less healthy? Think about diet, smoking, stress management and alcohol intake.

You can start making changes today that can have positive effects for the rest of your life. Not only will you feel better, but you will also be healthier.

 

Diet and Nutrition

One of the best things you can do after treatment is to put healthy eating habits into place. You will be surprised at the long-term benefits of some simple changes, like increasing the variety of healthy foods that you eat. Try to eat 5 servings of vegetables and fruits each day. Choose whole grains instead of white flour and sugars. Try to limit meats that are high in fat. Cut back on processed foods. If you drink alcohol, limit yourself to 1 drink a day at the most. And get regular exercise. The combination of a balanced diet and exercise will keep you feeling more energetic and help you maintain a healthy weight which will reduce your risk of the cancer coming back.

 

Sexual Health

This is probably the least talked about aspect of your life that is affected after a diagnosis of breast cancer.

Physical changes after surgery may make some women feel uncomfortable about their bodies. There may be decreased breast sensation or the breasts may be hypersensitive.

Treatments like chemotherapy and hormone therapy can change your hormone levels and affect your sexual interest or response. You may have symptoms of menopause like hot flushes, vaginal dryness and menstrual cycle changes. In spite of these changes you should still be able to have meaningful sex and reach orgasm. Vaginal dryness can be improved with various creams or lotions. Your partner may also feel unsure how to express love emotionally and physically which can lead to tension in relationships.

Breast cancer can be a positive growth experience for couples when partners acknowledge potential problems, are more aware of what to expect and engage actively in seeking advice.