Cancer

Sometimes in lonely nights I wonder why there aren't more starsigns named after deadly illnesses, but then after I while the fact occurs to me, that nobody died of cancer when they named them back then. Nobody was old enough in those days.

I'd still love to hear women approach each other, asking for their signs. »I'm multiple sklerosis and my friend is alzheimers« – »Oh, that's like so terrible, you just don't match«.

I tend to think, it would be a better world. And I'm not even a Cancer.

For nearly 80 percent of women with breast cancer, the discovery of a mass or
lump in the breast is the first sign that something is amiss. Fortunately, 8 out of
every 10 lumps discovered and biopsied turn out to be noncancerous, but if you
do find a suspicious lump, its still best to call your doctor right away.

Most women discover breast lumps themselves, either by accident or while
performing a monthly self-examination. Because early detection is crucial for a
cure, you need to learn the right way to examine your breasts each month. Once you know the feel of a »normal« breast, youll quickly
recognize any little change.
If you do find a lump, your breast may be tender, or it may feel normal. There
could be some discomfort or a »pulling sensation.« Cysts, which are benign, tend
to move freely within the breast, so when a lump appears to be immobile, or the
skin is dimpled or puckered, doctors tend to suspect that the growth is malignant.
However, this is not a certainty.

A discharge from the nipple is another common sign of a potential problem. The
discharge may be clear, bloody, or colored. It is important to understand that a
discharge can be perfectly normal in women who are not breastfeeding. In this
case, a small amount of discharge usually comes out of several openings in both
breasts.

A spontaneous discharge that occurs without squeezing the breast is a far greater
cause for concern. A discharge coming from the same general location in one
breast may well indicate the presence of an underlying mass. Although a bloody
discharge occasionally may occur during pregnancy, it can also be a significant
warning sign of cancer. The older the woman, the greater the possibility that the
discharge is caused by cancer. The odds are even higher if she also has a lump.

Other signs of cancer include a change in the shape or size of the breast or
swelling of the skin that covers it. The breast tissue may feel thicker, even though
there is no lump. There may be pain or redness of the skin. The nipple may be
sore or retract inside the breast. You should have a skin-doctor examine any sores on
the nipples or breast that do not clear up after two weeks of treatment with a
prescribed cream or lotion. Its also important to tell a doctor about scaly skin on
the nipple, skin dimpling, and any change in the veins in the breast. In most cases,
the doctor will need to take a sample for microscopic examination (a biopsy) to
check for cancer.

As breast cancer progresses, signs and symptoms become unmistakable,
including skin ulcers and extensive swelling and redness of the breast and swelling
of the arm. The nipple may retract into the breast, and the breast may retract into
the chest.

There are many different types of surgery for breast cancer. Options include
removing the whole breast and certain other tissues (radical, modified radical, and
total mastectomy) or removing only the lump with or without some tissue around
it (lumpectomy and partial mastectomy). The latter options are known as "breast
conservation» or «breast conserving therapy," as they allow a woman to keep
some of her breast. Breast conserving therapy is followed by radiation therapy; a
full mastectomy may not require it. Long-term cure rates with breast conserving
therapy are identical to those with mastectomy in women who qualify for the less
destructive procedure.

According to guidelines developed by the National Cancer Institute,
approximately 75 percent of women diagnosed with early stage (Stage I or II)
breast cancer are eligible for breast conserving therapy. Mastectomy is more
appropriate in early-stage cancers only for women with large tumors, small breast
size in comparison to tumor size, or multiple tumors in various parts of the breast,
and for those in an early-stage of pregnancy. One study indicates that many
women eligible for breast conserving therapy wind up with a mastectomy, so be
sure to quiz the doctor carefully about the breast conserving option.

In any of these procedures, the surgeon may also remove some – and possibly
all – of the lymph nodes under the arm. The lymph nodes are part of the bodys
lymphatic system, which filters waste from the tissues and carries fluids that help
the body fight infection. The lymphatic system transports fluids very efficiently
and, if invaded by cancer cells, can carry them throughout the body.

Surgeons remove at least a sampling of the lymph nodes near the breast to check
whether the cancer has reached the nodes. The extent of »nodal involvement« --
the number of lymph nodes with cancer – helps the physician determine how
much radiation or chemotherapy a woman needs after surgery. Removal of
underarm lymph nodes also is intended to help prevent cancer from recurring in
the same breast area.

Unfortunately, this procedure often leads to pain, as well as reduced use of the
arm and shoulder, for nearly 3 years after surgery. Investigators are trying to
determine whether removing only one or a few lymph nodes from under the arm
 – a technique known as sentinel node biopsy – is as effective as removing more
nodes. If so, doctors will need to remove just the nodes that cancer cells would
reach first. Only if these nodes show evidence of cancer would others need
removal.

For many years, women went into the hospital for a biopsy not even knowing
whether they even had cancer and often woke up several hours later to find that
their breast was gone. Advocates of this one-step approach to biopsy and
treatment believed that a simple surgical procedure involved less risk than waiting
between biopsy and surgery. Treatment began immediately and the woman had
less stress and anxiety because the ordeal was over much sooner. The one-step
approach was also cheaper and involved only one hospitalization.

Times have changed. Many women and physicians now favor the two-step
approach. This not only allows the doctor time to better evaluate the disease, but
also gives the patient a chance to consider the different treatment possibilities,
obtain a second opinion if she wants, make any necessary arrangements at work
or at home, and get herself mentally and emotionally ready to fight the disease.

The trend toward shortened hospital stays is evident in breast cancer surgery.
Lumpectomy is usually performed in an outpatient surgery center. Women
undergoing a mastectomy and/or removal of underarm lymph nodes generally
stay in the hospital for no more than 1 or 2 nights. Mastectomy patients are
occasionally hospitalized for as long as 5 days, but some may be discharged from
a short-stay observation unit in as little as 23 hours. In this situation, a home care
nurse typically monitors the patient. Many women are now discharged with a
surgical drain in place.

Whatever treatment a woman chooses, she needs to have her physicians support.
Its very important for doctor and patient to discuss the situation thoroughly and
make sure they agree on whats best. The bottom line for most women is to go
with the approach that offers them the best chance for survival. There are many
choices:

Radical Mastectomy

In a radical mastectomy, the surgeon removes the entire breast, both chest
muscles, and all of the lymph nodes under the arm. Also known as the Halsted
radical mastectomy, after the surgeon who developed the procedure in the
1890s, this operation used to be the standard breast cancer treatment.

There were many drawbacks to such extensive surgery. Women sometimes lost
movement in the arm and shoulder and experienced numbness, discomfort, and
swelling of the arm. The surgery was very disfiguring – some called it mutilation.
After the operation, the chest looked hollow and the scar unsightly. Breast
reconstruction was possible, but very difficult.

Over the years, scientific studies have shown that removing the chest muscles
doesnt improve a womans prognosis and isnt necessary if the cancer is found
early. Today, doctors perform radical mastectomies only when the tumor has
spread to the chest muscles.

Modified Radical Mastectomy

The modified radical mastectomy is an updated version of the standard radical
and is the most common surgical procedure performed for breast cancer. The
operation involves removing the breast, the lymph nodes, and the lining that
covers the two chest muscles. The muscles themselves are usually left in place,
although the smaller muscle is sometimes removed.

This operation delivers survival rates for women with early breast cancer that are
just as good as those achieved with a radical mastectomy. The surgery effectively
removes local cancer without causing muscle and nerve damage. Women
experience fewer complications and have more muscle strength in the arm.

The chest also looks a lot better, and this can be a great morale booster. In
addition, breast reconstruction is much easier to perform after a modified radical.

Although many women dont decide to have reconstruction until several months or
even years after their cancer surgery, it is important to discuss the possibility
beforehand so that the surgeon can help prepare the area for eventual operation.
The type of incision used in the mastectomy, for example, can make a big
difference in subsequent reconstructive surgery.

Total or Simple Mastectomy

In this operation, the surgeon removes the breast and maybe a few of the lymph
nodes closest to the breast. Presumably, any invasion of cancer cells will show up
in these lymph nodes first.

The benefits of this approach include a great reduction in swelling, because most
(or all) of the lymph nodes are left alone. The operation also makes breast
reconstruction easier than does more extensive surgery.

Partial or Segmental Mastectomy

With this procedure, the surgeon removes the tumor along with a portion of the
tissue around it. This wedge also includes some skin and the lining of the chest
muscle just below the tumor. The surgeon may also remove some or all of the
lymph nodes. Women who have this type of surgery also receive radiation
therapy.

If the breast is large, this approach leaves most of it intact. However, a woman
with smaller breasts will definitely see a change in breast shape after the surgery.
The amount of postoperative swelling generally depends on the number of lymph
nodes removed. Loss of muscle strength in the arm is not a problem.

Lumpectomy

The popular name for this operation, which involves removing only the tumor, is
somewhat misleading. Many surgeons also take out the lymph nodes through a
second incision in the armpit. Radiation therapy follows the surgery.

Lumpectomy is not without some drawbacks. The resulting scar tissue in the
breast can make follow-up breast examinations difficult. Swelling in the arm is a
possibility whenever lymph nodes are removed.

Women who have a large lump removed from a small breast are likely to notice a
significant change in the shape of the breast. Since the procedure itself can make
it more difficult to correct any resulting »deformities,« many plastic surgeons do
not recommend a lumpectomy for small-breasted women or those whose tumor
is located under the nipple.

On the other hand, many women do not need reconstruction after a lumpectomy.
To make a decision, you really need to discuss the prospects with both a general
surgeon and a plastic surgeon.

All breast cancer results from changes in genes, but not all changes in the genes
are inherited. In fact, only about 5 to 10 percent of breast cancers are thought to
be caused by inheritance. Scientists have identified some of the genetic
alterations, or mutations, that are responsible. In particular, women with
mutations in genes called BRCA 1 or BRCA 2 (for breast cancer 1 or 2) are in
greater danger of breast cancer. Statistics indicate that about 50 to 60 percent of
women with a mutation in either gene will develop breast cancer by the age of 70.
These mutations also increase a womans risk of ovarian cancer, and possibly of
colon cancer. And they tend to promote development of breast cancer at a
younger than average age.

Women with an abnormal AT (ataxia telangiectasia) gene are also thought to be
at increased risk of breast cancer. Likewise, abnormalities in the p53 tumor
suppressor gene can increase a womans risk. Theres also some evidence that
women of Ashkenazi Jewish descent may be at higher risk of carrying a genetic
mutation associated with breast cancer.

Its important to remember that a case of breast cancer in your family does not
automatically mean that you carry a gene associated with the disease. After all,
breast cancer is relatively common in women without a genetic mutation. A family
history of both breast and ovarian cancer increases the likelihood that you carry
such a mutation, but does not guarantee it.

You can find out whether you have the BRCA 1 or BRCA 2 mutation by getting
a blood test. If you have a family history of breast cancer, theres good reason to
be tested, but there are pluses and minuses to knowing for sure. Confirmation of
the abnormality can alert you to the need for lifestyle changes you might otherwise
have dismissed. It can also weigh heavily in the decision to undergo drug therapy
or a mastectomy to reduce the risk of breast cancer (see chapter 37 for more
details). On the other hand, a positive reading could result in loss of health
insurance, inability to obtain insurance, or an increase in premiums to an
unaffordable level.