The stage of cancer is determined by the size of the tumor and the presence or absence of spread to the lymph nodes and other areas of the body. While often the stage can be estimated by imaging studies of the breast (such as mammogram, ultrasound, and MRI) or imaging of the body (such as CT scan, PET/CT scan, bone scan), the pathologic stage can only be determined after the tumor and lymph node(s) have been removed and have been evaluated by the pathologist. Examination under the microscope remains the most accurate way to determine if the cancer has spread to the underarm lymph nodes (assuming that they are not abnormally enlarged). If a woman has received chemotherapy prior to surgery, the "true" pathologic stage may never be known, as the tumor will often decrease significantly in size as a result of preoperative chemotherapy. The stage of cancer is determined by the size of the tumor and the presence or absence of spread to the lymph nodes and other areas of the body. While often the stage can be estimated by imaging studies of the breast (such as mammogram, ultrasound, and MRI) or imaging of the body (such as CT scan, PET/CT scan, bone scan), the pathologic stage can only be determined after the tumor and lymph node(s) have been removed and have been evaluated by the pathologist. Examination under the microscope remains the most accurate way to determine if the cancer has spread to the underarm lymph nodes (assuming that they are not abnormally enlarged). If a woman has received chemotherapy prior to surgery, the "true" pathologic stage may never be known, as the tumor will often decrease significantly in size as a result of preoperative chemotherapy.

There are many ways to perform risk assessment, and the most important is by taking a personal and family history. A prior breast biopsy, especially if it demonstrated "atypical hyperplasia", increases a woman's risk for the future development of breast cancer. Also the number of relatives who have had breast cancer, and their age at diagnosis, is also important. A history of other cancers in the family, especially ovarian cancer, may lead to a recommendation for BRCA gene testing.

There are various risk assessment models available - the most commonly used one is the Gail Model: http://www.cancer.gov/bcrisktool/ and it uses known risk factors such as age, age at first menstrual period and first term pregnancy, whether or not prior biopsies have been performed (and if so, was atypia present?), and family history. A disadvantage of the Gail model is that it only takes into account first-degree relatives (mother, sister, daughter) and it may underestimate the risk of disease in some women.

A form of genetic testing, known as the OnvoVue test, is a saliva test which assesses various genes involved in breast cancer development; results are reported as standard risk, moderately elevated, and significantly elevated - this test can help us determine if an otherwise asymptomatic woman might be at higher risk for the future development of breast cancer. Additional information on the OncoVue test can be found here - http://www.cancerriskassessment.com/what-is-oncovue-2.

Another form of risk assessment testing uses milk duct fluid (nipple aspirate fluid) to determine if there are abnormal cells present; the presence of abnormal cells or atypia would mean that a woman is at increased risk for the development of breast cancer and additional testing may be recommended.

Realize that no risk assessment test is a crystal ball - we do not at this point have the ability to predict with certainty if someone will or will not develop breast cancer. However they can help to identify women that might be at higher than average risk for which additional testing might be indicated. Additional information on risk assessment can be found here - http://www.cfbci.com/halo.html. There are many ways to perform risk assessment, and the most important is by taking a personal and family history. A prior breast biopsy, especially if it demonstrated "atypical hyperplasia", increases a woman's risk for the future development of breast cancer. Also the number of relatives who have had breast cancer, and their age at diagnosis, is also important. A history of other cancers in the family, especially ovarian cancer, may lead to a recommendation for BRCA gene testing.

There are various risk assessment models available - the most commonly used one is the Gail Model: http://www.cancer.gov/bcrisktool/ and it uses known risk factors such as age, age at first menstrual period and first term pregnancy, whether or not prior biopsies have been performed (and if so, was atypia present?), and family history. A disadvantage of the Gail model is that it only takes into account first-degree relatives (mother, sister, daughter) and it may underestimate the risk of disease in some women.

A form of genetic testing, known as the OnvoVue test, is a saliva test which assesses various genes involved in breast cancer development; results are reported as standard risk, moderately elevated, and significantly elevated - this test can help us determine if an otherwise asymptomatic woman might be at higher risk for the future development of breast cancer. Additional information on the OncoVue test can be found here - http://www.cancerriskassessment.com/what-is-oncovue-2.

Another form of risk assessment testing uses milk duct fluid (nipple aspirate fluid) to determine if there are abnormal cells present; the presence of abnormal cells or atypia would mean that a woman is at increased risk for the development of breast cancer and additional testing may be recommended.

Realize that no risk assessment test is a crystal ball - we do not at this point have the ability to predict with certainty if someone will or will not develop breast cancer. However they can help to identify women that might be at higher than average risk for which additional testing might be indicated. Additional information on risk assessment can be found here - http://www.cfbci.com/halo.html.

Most of the time the breast surgeon will want to review all of your records, so make sure you have all reports from mammograms, ultrasound, MRI exams, and any biopsy pathology. In addition, most breast surgeons will want to view the actual films (often they are provided on a CD), not just the reports. Your history will be taken and questions will be asked not only about the current problem, but of any other breast-related problem. Other medical history and family history will also be reviewed. A breast examination will also be performed and additional imaging such as ultrasound may also be performed.

When you make the appointment, ask if there is paperwork that you can fill out ahead of time; many of our patients find it helpful to fill out their paperwork in consultation with another family member so that important medical conditions and family history are included. Providing your surgeon with as much information as possible will ensure that you receive a thorough consultation. Most of the time the breast surgeon will want to review all of your records, so make sure you have all reports from mammograms, ultrasound, MRI exams, and any biopsy pathology. In addition, most breast surgeons will want to view the actual films (often they are provided on a CD), not just the reports. Your history will be taken and questions will be asked not only about the current problem, but of any other breast-related problem. Other medical history and family history will also be reviewed. A breast examination will also be performed and additional imaging such as ultrasound may also be performed.

When you make the appointment, ask if there is paperwork that you can fill out ahead of time; many of our patients find it helpful to fill out their paperwork in consultation with another family member so that important medical conditions and family history are included. Providing your surgeon with as much information as possible will ensure that you receive a thorough consultation.

No - many women have "lumpy" breasts which is usually related to the combination of glandular tissue and fatty tissue in the breast, but lumpy is not the same as dense. Breast density refers to the appearance of the breast tissue on imaging, usually mammogram. Dense breast tissue appears more "white" on mammogram, which makes it harder to detect cancer, also usually "white" on mammogram. Younger women naturally have dense breast tissue, but some women still have dense breast tissue even as they get older. Hormone therapy will maintain the dense breast appearance on mammogram.

Women with dense breast tissue on imaging are at higher risk for the future development of breast cancer, and as mammograms may miss more cancers in women with dense breast tissue, additional imaging such as ultrasound or MRI may be helpful. No - many women have "lumpy" breasts which is usually related to the combination of glandular tissue and fatty tissue in the breast, but lumpy is not the same as dense. Breast density refers to the appearance of the breast tissue on imaging, usually mammogram. Dense breast tissue appears more "white" on mammogram, which makes it harder to detect cancer, also usually "white" on mammogram. Younger women naturally have dense breast tissue, but some women still have dense breast tissue even as they get older. Hormone therapy will maintain the dense breast appearance on mammogram.

Women with dense breast tissue on imaging are at higher risk for the future development of breast cancer, and as mammograms may miss more cancers in women with dense breast tissue, additional imaging such as ultrasound or MRI may be helpful.

Metastatic breast cancer means that the breast cancer has spread outside of the breast and outside of the underarm (axillary) lymph nodes. The most common sites of spread are to lymph nodes above the clavicle, in the chest, and to the lung, liver, bones, and brain. Metastatic breast cancer, or Stage IV breast cancer, is not considered curable, but modern treatments do allow for much longer survival with a better quality of life than older treatment regimens. Metastatic breast cancer means that the breast cancer has spread outside of the breast and outside of the underarm (axillary) lymph nodes. The most common sites of spread are to lymph nodes above the clavicle, in the chest, and to the lung, liver, bones, and brain. Metastatic breast cancer, or Stage IV breast cancer, is not considered curable, but modern treatments do allow for much longer survival with a better quality of life than older treatment regimens.

Stage 0 Breast cancer is also known as Ductal Carcinoma In-Situ, or DCIS. This means that the cancer cells are filling the milk ducts, but have not broken through the lining or wall of the milk duct. This means that the cancer generally does not have the potential to spread to other areas of the body. DCIS can be quite extensive throughout the breast however and sometimes mastectomy is needed. In addition, DCIS can be harder to detect on mammogram, ultrasound, or MRI, and often the extent of disease is underestimated by imaging. Stage 0 Breast cancer is also known as Ductal Carcinoma In-Situ, or DCIS. This means that the cancer cells are filling the milk ducts, but have not broken through the lining or wall of the milk duct. This means that the cancer generally does not have the potential to spread to other areas of the body. DCIS can be quite extensive throughout the breast however and sometimes mastectomy is needed. In addition, DCIS can be harder to detect on mammogram, ultrasound, or MRI, and often the extent of disease is underestimated by imaging.

Breast cysts are completely benign, in other words, not related to breast cancer. Think of them like little "water balloons" in the breast - they develop due to enlargement of an area of the milk duct that fills with fluid. They will often enlarge and may become painful right before the menstrual period, and then often decrease without any intervention. An ultrasound can be used to ensure that a lump is indeed a fluid filled cyst and not a solid tumor. "Simple" cysts, which have a thin wall and no solid growth associated with them can safely be observed, but sometimes fine needle aspiration is recommended if a cyst is large or painful. Breast cysts are completely benign, in other words, not related to breast cancer. Think of them like little "water balloons" in the breast - they develop due to enlargement of an area of the milk duct that fills with fluid. They will often enlarge and may become painful right before the menstrual period, and then often decrease without any intervention. An ultrasound can be used to ensure that a lump is indeed a fluid filled cyst and not a solid tumor. "Simple" cysts, which have a thin wall and no solid growth associated with them can safely be observed, but sometimes fine needle aspiration is recommended if a cyst is large or painful.

It depends on the patient and if reconstruction is performed, and what type of reconstruction. If a mastectomy without reconstruction is performed, usually a 24-48 hour hospital stay is required, and a patient is discharged with drainage tubes in place. The drains are usually removed after about 7-10 days, but may stay in place longer depending on the amount of fluid that is being produced. Overall recovery in terms of return to work and other normal activities can take anywhere from 2-3 weeks up to 6-8 weeks.

If reconstruction is performed using tissue expanders or implants, the recovery is similar to that of a mastectomy without reconstruction but the initial pain is usually more as the tissue expanders or implants are placed underneath the pectoralis muscle. If reconstruction using muscle or fatty tissue is performed, the hospital stay is usually 3-5 days, and may include an intensive care unit stay; overall recovery is typically 6-8 weeks and sometimes longer. It depends on the patient and if reconstruction is performed, and what type of reconstruction. If a mastectomy without reconstruction is performed, usually a 24-48 hour hospital stay is required, and a patient is discharged with drainage tubes in place. The drains are usually removed after about 7-10 days, but may stay in place longer depending on the amount of fluid that is being produced. Overall recovery in terms of return to work and other normal activities can take anywhere from 2-3 weeks up to 6-8 weeks.

If reconstruction is performed using tissue expanders or implants, the recovery is similar to that of a mastectomy without reconstruction but the initial pain is usually more as the tissue expanders or implants are placed underneath the pectoralis muscle. If reconstruction using muscle or fatty tissue is performed, the hospital stay is usually 3-5 days, and may include an intensive care unit stay; overall recovery is typically 6-8 weeks and sometimes longer.

The HALO test is a way to obtain fluid from the nipple which then can be analyzed to see if there are any abnormal, or atypical cells. Cellular atypia is a risk factor for the future development of breast cancer, and patients who have atypia usually are followed more closely. The HALO test is not a substitute for mammogram or other imaging as it is not meant to diagnose breast cancer - it is a way to determine if a woman might be at increased risk and therefore might need additional imaging. The HALO test is typically used in women under the age of 40, who are not yet undergoing routine screening with mammography.
The HALO test is a way to obtain fluid from the nipple which then can be analyzed to see if there are any abnormal, or atypical cells. Cellular atypia is a risk factor for the future development of breast cancer, and patients who have atypia usually are followed more closely. The HALO test is not a substitute for mammogram or other imaging as it is not meant to diagnose breast cancer - it is a way to determine if a woman might be at increased risk and therefore might need additional imaging. The HALO test is typically used in women under the age of 40, who are not yet undergoing routine screening with mammography.

Most often a woman will see a breast surgeon early in the process - either before diagnosis as many breast surgeons perform their own minimally invasive biopsies, or shortly after diagnosis. The breast surgeon will usually consult with the medical oncologist, radiation oncologist and plastic surgeon and the specialists will all work as a team to determine the breast treatment approach for a patient. Most often a woman will see a breast surgeon early in the process - either before diagnosis as many breast surgeons perform their own minimally invasive biopsies, or shortly after diagnosis. The breast surgeon will usually consult with the medical oncologist, radiation oncologist and plastic surgeon and the specialists will all work as a team to determine the breast treatment approach for a patient.

This may be a woman's individual choice - if a woman is a candidate for immediate reconstruction, she may have a preference regarding the timing of the surgery. Some prefer to undergo the mastectomy and other treatment first, delaying the reconstruction, while some women like the idea of having a large part of the reconstruction performed at the time of the mastectomy. Some patients with more aggressive tumors are not candidates for immediate reconstruction, but if the woman has a choice, it is really an individual decision. This may be a woman's individual choice - if a woman is a candidate for immediate reconstruction, she may have a preference regarding the timing of the surgery. Some prefer to undergo the mastectomy and other treatment first, delaying the reconstruction, while some women like the idea of having a large part of the reconstruction performed at the time of the mastectomy. Some patients with more aggressive tumors are not candidates for immediate reconstruction, but if the woman has a choice, it is really an individual decision.

Full preparation includes review of all imaging studies such as mammogram, ultrasound, and MRI, as well as consultation with appropriate specialists such as the medical oncologist, radiation oncologist, and plastic surgeon. Of course reviewing all options with the patient and making sure she is understands her treatment options and is comfortable with her decision is of utmost importance. Full preparation includes review of all imaging studies such as mammogram, ultrasound, and MRI, as well as consultation with appropriate specialists such as the medical oncologist, radiation oncologist, and plastic surgeon. Of course reviewing all options with the patient and making sure she is understands her treatment options and is comfortable with her decision is of utmost importance.

I would reinforce Dr. Moore's answer that not all breast findings need an MRI. There is no way that any of us can tell based on the information provided whether or not an MRI or other imaging will be helpful or necessary in this case - an understanding of the patient's clinical situation as well as review of the mammograms and any available pathology reports is necessary. In general, calcifications do not show up on MRI. There is no question that there are cancers that will show up on MRI that are missed by other imaging, but again each case needs to be properly evaluated before a blanket recommendation for MRI is made. There is no best imaging test for the breast, but that also does not mean that every test should be done in every person. Calcifications are very commonly seen in the breast. More than 50% of all mammograms performed have calcifications. The vast majority of them are related to benign or "normal" things. Surgery is one of the things that can produce calcifications. According to a recent Medscape article "high quality mammography is the best diagnostic tool for the identification of breast calcifications." When we interpret mammograms we characterize calcifications in terms of their their shape, number, distribution and size. We then categorize them as normal, benign, probably benign, or suspicious. Suspicious calcifications are biopsied, even though there is no palpable lump, or breast pain, or any other findings.

In one study 300 biopsies were performed on suspicious calcifications and only 100 of them were cancers. So even those that look suspicious are not always related to cancer.

MRI of the breast is a very sensitive test that is not always specific. If you have a lump that is palpable, or is seen on mammography or ultrasound, MRI may help. It can also find unsuspected small lesions as part of preoperative planning. MRI is not good at looking at calcification. Could MRI show you something really small that is in the area of the calcifications that is not seen on other tests? Possibly, but if the calcifications are in the area of the surgery MRI might be abnormal anyway, and more difficult to interpret.

Every case is different and every medical decision is made in the context of that patient's personal and family history, physical findings,and all imaging results. Patients are best served when they have a doctor who listens to them and whom they trust. Decisions are then made together. Unfortunately medicine is not an exact science, and our knowledge is still incomplete, in spite of the advances we have made.

Recurrence and survival statistics are based on historical studies as well as more current clinical trial results. It is important for an individual patient to realize that they are not a statistic, and that recurrence and survival rates can never be predicted with complete accuracy in a given patient. My recommendation is to be aware of the statistics as they pertain to your individual case, but do not hang all your hopes and fears on those numbers. Recurrence and survival statistics are based on historical studies as well as more current clinical trial results. It is important for an individual patient to realize that they are not a statistic, and that recurrence and survival rates can never be predicted with complete accuracy in a given patient. My recommendation is to be aware of the statistics as they pertain to your individual case, but do not hang all your hopes and fears on those numbers.

In general, the earlier the stage of diagnosis, the lower the risk of recurrence. However, with breast cancer or any cancer, we can never really say that a patient is truly “cured” – sometimes “NED” – no evidence of disease – is the best we can do. We do not yet have the ability to detect individual metastatic cells which may be slowly growing, only to show up on a scan years later. We are also learning more about breast cancer and while the stage at initial diagnosis is important, the biologic behavior, or aggressiveness of the cancer, may be even more important in terms of assessing an individual patient’s risk of recurrence. In general, the earlier the stage of diagnosis, the lower the risk of recurrence. However, with breast cancer or any cancer, we can never really say that a patient is truly “cured” – sometimes “NED” – no evidence of disease – is the best we can do. We do not yet have the ability to detect individual metastatic cells which may be slowly growing, only to show up on a scan years later. We are also learning more about breast cancer and while the stage at initial diagnosis is important, the biologic behavior, or aggressiveness of the cancer, may be even more important in terms of assessing an individual patient’s risk of recurrence.

The duration of treatment is very variable, depending on the exact type of cancer, the biologic behavior of the cancer (how aggressive it is), and the stage of diagnosis. Some cases of breast cancer, especially low-grade DCIS, may be treated by surgery alone; some cases of breast cancer are treated with a combination of surgery, chemotherapy, radiation therapy, and anti-estrogen therapy. Radiation therapy, if needed is now able to be administered in several ways, including intraoperative therapy, accelerated partial-breast irradiation, accelerated whole-breast irradiation, and standard whole breast therapy – with the newer forms of more concentrated therapy, the duration of treatment is often significantly reduced. There are multiple chemotherapy and targeted therapy regimens, which may range in duration from several months to years. In some cases of metastatic disease, continued maintenance chemotherapy is required. The duration of treatment is very variable, depending on the exact type of cancer, the biologic behavior of the cancer (how aggressive it is), and the stage of diagnosis. Some cases of breast cancer, especially low-grade DCIS, may be treated by surgery alone; some cases of breast cancer are treated with a combination of surgery, chemotherapy, radiation therapy, and anti-estrogen therapy. Radiation therapy, if needed is now able to be administered in several ways, including intraoperative therapy, accelerated partial-breast irradiation, accelerated whole-breast irradiation, and standard whole breast therapy – with the newer forms of more concentrated therapy, the duration of treatment is often significantly reduced. There are multiple chemotherapy and targeted therapy regimens, which may range in duration from several months to years. In some cases of metastatic disease, continued maintenance chemotherapy is required.

Noninvasive means that the cancer cells have not spread or penetrated through the basement membrane - the thin layer that lines the milk ducts and lobules. An invasive cancer occurs when the basement membrane is disrupted by the invading cancer cells; those cancer cells then have the potential to invade blood vessels or lymphatic vessels.

Ductal carcinoma in-situ (DCIS), is considered Stage 0 – the cancer cells have not invaded the basement membrane. Lobular carcinoma in-situ (LCIS) is not actually considered a cancer, despite the name, and many now refer to this condition as “lobular neoplasia” to avoid confusion. Patients with LCIS often do require surgical excision, but generally are not treated with additional therapy such as radiation therapy or chemotherapy. However patients with LCIS are at a significantly increased risk for the future development of breast cancer (in-situ or invasive) in either breast, so often anti-estrogen medication such as tamoxifen or an aromatase inhibitor may be recommended for risk reduction. In addition, increased surveillance may be indicated in these patients.
Noninvasive means that the cancer cells have not spread or penetrated through the basement membrane - the thin layer that lines the milk ducts and lobules. An invasive cancer occurs when the basement membrane is disrupted by the invading cancer cells; those cancer cells then have the potential to invade blood vessels or lymphatic vessels.

Ductal carcinoma in-situ (DCIS), is considered Stage 0 – the cancer cells have not invaded the basement membrane. Lobular carcinoma in-situ (LCIS) is not actually considered a cancer, despite the name, and many now refer to this condition as “lobular neoplasia” to avoid confusion. Patients with LCIS often do require surgical excision, but generally are not treated with additional therapy such as radiation therapy or chemotherapy. However patients with LCIS are at a significantly increased risk for the future development of breast cancer (in-situ or invasive) in either breast, so often anti-estrogen medication such as tamoxifen or an aromatase inhibitor may be recommended for risk reduction. In addition, increased surveillance may be indicated in these patients.

The type of breast cancer is generally determined by the microscopic appearance of the tumor. When the pathologist examines the tissue, either from a needle core biopsy or surgical excision, they make a determination if the cells are ductal or lobular in origin, and whether or not invasion is present. There are times when it is difficult to tell exactly what type of cancer is present – breast cancers can have a variable appearance and the diagnosis is not always obvious by the initial microscopic appearance. A variety of special stains may be used, and these additional tests can confirm if a tumor is ductal or lobular (some cancers are “mixed” , having features of both cell types), of if invasion is present or not. The type of breast cancer is generally determined by the microscopic appearance of the tumor. When the pathologist examines the tissue, either from a needle core biopsy or surgical excision, they make a determination if the cells are ductal or lobular in origin, and whether or not invasion is present. There are times when it is difficult to tell exactly what type of cancer is present – breast cancers can have a variable appearance and the diagnosis is not always obvious by the initial microscopic appearance. A variety of special stains may be used, and these additional tests can confirm if a tumor is ductal or lobular (some cancers are “mixed” , having features of both cell types), of if invasion is present or not.

I did transition to a gluten-free diet a few years ago for medical reasons, but that doesn't make me a grains expert! There are a number of health benefits to whole grains including a higher fiber and vitamin intake. Whole grains certainly have a place in a good balanced diet. While whole grains are healthier than heavily processed grains, as I know, there are no studies conclusively linking white flour and other heavily processed grains to malignancy. The same is probably true for organic - organic foods will have less potential for contamination due to pesticides and other chemicals, but at this point we do not have any evidence to suggest that eating organic foods will reduce your cancer risk. I usually recommend that my patients stick to the most natural, unprocessed diet that they are comfortable with in order to optimize their overall health - what the optimal diet really consists of is still the subject of much debate. I did transition to a gluten-free diet a few years ago for medical reasons, but that doesn't make me a grains expert! There are a number of health benefits to whole grains including a higher fiber and vitamin intake. Whole grains certainly have a place in a good balanced diet. While whole grains are healthier than heavily processed grains, as I know, there are no studies conclusively linking white flour and other heavily processed grains to malignancy. The same is probably true for organic - organic foods will have less potential for contamination due to pesticides and other chemicals, but at this point we do not have any evidence to suggest that eating organic foods will reduce your cancer risk. I usually recommend that my patients stick to the most natural, unprocessed diet that they are comfortable with in order to optimize their overall health - what the optimal diet really consists of is still the subject of much debate.

The American Cancer Society has a publication "Exercises after breast cancer surgery" - it's a booklet with diagrams of exercises that I find to be helpful. The link is here: http://www.cancer.org/Cancer/BreastCancer/MoreInformation/exercises-after-breast-surgery I would assume that if you are back to work you are at least 6 to 8 weeks out of surgery. Most doctors will recommend you don't start an exercise program until you are 6 to 8 weeks out of surgery, so make sure you have your doctor's permission to exercise before starting a program. That being said, I always start with flexibility and range of motion. After surgical procedures related to breast cancer, we have a tendency to sort of hunch over in a forward position which causes tightening in the chest muscles and weakness in the upper back muscles. If you are going back to work in an office, this would probably mean you are sitting at a desk and working on a computer, which puts you automatically in the above-mentioned position. So, what are some exercises you can do at work to regain range of motion and flexibility?

I would start by sitting up straight in your chair, and doing some shoulder rolls. Shoulder rolls are great because they "set" your posture. So sit up straight in your chair and squeeze your shoulders up towards your ears, then drop them down while squeezing them back towards each other, then drop them down as if you are putting your shoulder blades in your back pocket. This is an exaggerated version of a shoulder roll, but it gets your shoulders moving and pulls them down and back where they belong. Try a few of these by doing the exaggerated version first, then simply roll them up, back and down.

Let me know if this helps!!

For a video of flexibility exercises you can do at home or at work, go to http://www.movingonfromcancer.com

I use the HALO test fairly often in my practice. It is true that approximately 50% of women will produce fluid. Those that do not produce fluid are considered to have had a normal test, and it is unlikely that they have any abnormality of their milk ducts. If fluid is produced, it is sent for cytology evaluation to see if there are abnormal cells present. Some studies have suggested that if a condition called atypia is present, it has the same significance of atypical ductal hyperplasia found on needle biopsy, which leads to an increased risk of breast cancer in the future.

As the women undergoing the HALO test are often younger than 40 and not undergoing routine mammogram screening, if a patient has atypia found on the HALO test, I would likely recommend that she begin screening, possibly with ultrasound and MRI in addition to mammogram, earlier than age 40. However as pointed out by Dr. Bone, this can open up a whole host of other issues, including radiation exposure and false positive test results.

It is important to remember that the HALO test is not meant to detect breast cancer or to be a screening test for breast cancer. It is a form of risk assessment, meant to help us sort out if a woman should undergo screening when she normally would not. I generally do not recommend that the HALO test be performed on women over age 45. The HALO test is based on data that showed that women with nipple discharge had a higher risk of breast cancer over the course of their lives. A machine that looks and acts a lot like a breast pump massages the breast and uses a vacuum-like action to seek fluid. Unfortunately, a large number of women will have nipple fluid in this circumstance, some say as high as 50%. Trying to figure out what to do with them afterward is a challenge. Data have shown that send nipple aspirated fluid for cytologic evaluation is not particularly helpful in figuring out who is at risk, nor does it diagnose or rule out cancer definitively. I have found that it makes women more anxious. The theory is that these women will be followed more closely, but that is a double-edged sword. They undergo more testing and probably more biopsies, but ultimately I have not seen data proving that more lives are saved.

As for BREVAGEN, it is a model based on combining the Gail Model (a risk assessment tool that is known to be inaccurate for many reasons) with a mouth swab looking for 7 single nucleotide polymorphisms (SNPs) which can modify the Gail risk upward or downward. In the fine print of the test, it acknowledges that it works best in Caucasians over the age of 35. It doesn't take into account breast cancer in the father's side, second- and third-degree relatives with cancer, nor does it consider other related cancers as risk factors. The idea is an interesting one, but needs to be developed further.

Thanks for the great question! I always considered myself to be fairly healthy, but the reality is it was not until I got sick a few years ago that I really got the wake-up call. The gluten-free diet was a part of my whole "transformation", which has included a transition to a non-processed, primarily plant-based diet, much of which I (try) to grow myself! It has also given me a real appreciation for the amazing healing capacity of our bodies and spirits, as well a much better appreciation of what my limits truly are. While I still try to push through those limits, I'm much more accepting of my boundaries than ever before. I wrote a little about my dietary changes here: http://www.morrisonhealth.com/blog/health/dr-attais-gluten-free-diet . I also feel that what I've gone through personally has made me a much better physician; dealing with illness and recovery as a patient has taught me things that medical school and 16 years of clinical practice did not even touch! Thanks for the great question! I always considered myself to be fairly healthy, but the reality is it was not until I got sick a few years ago that I really got the wake-up call. The gluten-free diet was a part of my whole "transformation", which has included a transition to a non-processed, primarily plant-based diet, much of which I (try) to grow myself! It has also given me a real appreciation for the amazing healing capacity of our bodies and spirits, as well a much better appreciation of what my limits truly are. While I still try to push through those limits, I'm much more accepting of my boundaries than ever before. I wrote a little about my dietary changes here: http://www.morrisonhealth.com/blog/health/dr-attais-gluten-free-diet . I also feel that what I've gone through personally has made me a much better physician; dealing with illness and recovery as a patient has taught me things that medical school and 16 years of clinical practice did not even touch!

Most breast surgery is performed under general, or total anesthesia. General anesthesia is very safe, but not without some risk of complication. Most commonly, a combination of medications is used - usually an inhalational agent (anesthetic gas), a narcotic (morphine derivative) for pain control, amnestic agent (medications similar to valium), and an intravenous anesthetic agent are used. Using multiple agents that have different mechanisms of action means that lower doses of each drug can be used. Anti-nausea medications are often used as well. The anesthetic medications currently used are all relatively short-acting, which minimizes the "hangover" effect of the general anesthesia. However some patients still will take a long time to wake up, or may have significant nausea after surgery.

Some lumpectomies are performed using local anesthesia with intravenous sedation ("twilight sleep"). Some centers are starting to use regional blocks for mastectomy cases, so that the patient is awake or just lightly sedated, but numb in the area of the surgery - in some studies this has shown to decrease the amount of narcotics used after surgery which may reduce nausea. Most breast surgery is performed under general, or total anesthesia. General anesthesia is very safe, but not without some risk of complication. Most commonly, a combination of medications is used - usually an inhalational agent (anesthetic gas), a narcotic (morphine derivative) for pain control, amnestic agent (medications similar to valium), and an intravenous anesthetic agent are used. Using multiple agents that have different mechanisms of action means that lower doses of each drug can be used. Anti-nausea medications are often used as well. The anesthetic medications currently used are all relatively short-acting, which minimizes the "hangover" effect of the general anesthesia. However some patients still will take a long time to wake up, or may have significant nausea after surgery.

Some lumpectomies are performed using local anesthesia with intravenous sedation ("twilight sleep"). Some centers are starting to use regional blocks for mastectomy cases, so that the patient is awake or just lightly sedated, but numb in the area of the surgery - in some studies this has shown to decrease the amount of narcotics used after surgery which may reduce nausea.

In general, a lumpectomy (most often performed with a sentinel lymph node biopsy) is done as an outpatient surgery, meaning the woman will go home the same day. The usual time to return to fully normal activities can be anywhere from 1-4 weeks, depending on the patient, underarm discomfort (generally this is worse than the breast discomfort) and various other factors.

After a mastectomy, some patients go home the same day, although I think most commonly patients are in the hospital for 24-48 hours. I will also depend if reconstruction is performed and what type - patients that undergo muscle flap reconstruction may spend 3-5 days in the hospital. Recovery can vary from just a few weeks up to 6-8 weeks, again depending on the type of surgery / reconstruction, amount of pain, and other factors. After mastectomy, drainage tubes are commonly left in place and may remain for 1-2 weeks. In general, a lumpectomy (most often performed with a sentinel lymph node biopsy) is done as an outpatient surgery, meaning the woman will go home the same day. The usual time to return to fully normal activities can be anywhere from 1-4 weeks, depending on the patient, underarm discomfort (generally this is worse than the breast discomfort) and various other factors.

After a mastectomy, some patients go home the same day, although I think most commonly patients are in the hospital for 24-48 hours. I will also depend if reconstruction is performed and what type - patients that undergo muscle flap reconstruction may spend 3-5 days in the hospital. Recovery can vary from just a few weeks up to 6-8 weeks, again depending on the type of surgery / reconstruction, amount of pain, and other factors. After mastectomy, drainage tubes are commonly left in place and may remain for 1-2 weeks.

"NED" stands for "no evidence of disease" and is probably the term most often used to describe a patient's status after treatment. Unfortunately, we can never truly say a patient is cured of cancer - the best we can do is say that we find no evidence of it. I will often tell my early-stage (lymph node negative) patients after surgery that they have no evidence of disease, and the medical oncologists will use the term after they've evaluated scans and bloodwork and find no abnormality.

It's important to realize that you can have areas of cancer, not detected by scans or blood tests, and still be considered NED. I'd look at NED as not perfect (very few things in life are), but still a good place to be. "NED" stands for "no evidence of disease" and is probably the term most often used to describe a patient's status after treatment. Unfortunately, we can never truly say a patient is cured of cancer - the best we can do is say that we find no evidence of it. I will often tell my early-stage (lymph node negative) patients after surgery that they have no evidence of disease, and the medical oncologists will use the term after they've evaluated scans and bloodwork and find no abnormality.

It's important to realize that you can have areas of cancer, not detected by scans or blood tests, and still be considered NED. I'd look at NED as not perfect (very few things in life are), but still a good place to be.

It's very important to realize that there is NO difference in overall survival if a woman undergoes mastectomy versus lumpectomy + radiation therapy - this is why we can offer women with relatively small breast cancers the option of breast conservation. It is still thought by many women that they will live longer if they undergo mastectomy, but this simply is not true.

With modern treatment, the risk of local recurrence (in the skin or chest wall) after mastectomy is approximately 1-3%. After lumpectomy and radiation therapy it is slightly higher, but with attention to obtaining clear margins, it can be less than 5%. It's very important to realize that there is NO difference in overall survival if a woman undergoes mastectomy versus lumpectomy + radiation therapy - this is why we can offer women with relatively small breast cancers the option of breast conservation. It is still thought by many women that they will live longer if they undergo mastectomy, but this simply is not true.

With modern treatment, the risk of local recurrence (in the skin or chest wall) after mastectomy is approximately 1-3%. After lumpectomy and radiation therapy it is slightly higher, but with attention to obtaining clear margins, it can be less than 5%.

Usually after mastectomy and reconstruction, imaging such as mammogram is not performed as all or almost all of the breast tissue is removed. MRI is sometimes performed every few years, but primarily to assess the integrity of silicone implants, if they were used for the reconstruction.

There are no standard recommendations for imaging in a patient that has undergone mastectomy and implant reconstruction - usually careful physical exam every 6 months is recommended as a recurrence will most often present as a palpable lump (able to be felt). In cases where it is difficult to differentiate scar tissue from recurrence, biopsy is usually performed.

If reconstruction is performed using a muscle flap, MRI or ultrasound are probably the most helpful tests to rule out recurrence, but again there are no standard recommendations for post-mastectomy imaging. Usually after mastectomy and reconstruction, imaging such as mammogram is not performed as all or almost all of the breast tissue is removed. MRI is sometimes performed every few years, but primarily to assess the integrity of silicone implants, if they were used for the reconstruction.

There are no standard recommendations for imaging in a patient that has undergone mastectomy and implant reconstruction - usually careful physical exam every 6 months is recommended as a recurrence will most often present as a palpable lump (able to be felt). In cases where it is difficult to differentiate scar tissue from recurrence, biopsy is usually performed.

If reconstruction is performed using a muscle flap, MRI or ultrasound are probably the most helpful tests to rule out recurrence, but again there are no standard recommendations for post-mastectomy imaging.

Thanks for the question - cryoablation is fascinating technology, and involves freezing a lesion and then essentially letting nature run it's course. The freezing destroys the tumor cells, and the body then reabsorbs the dead cells. Cryoablation is not new technology, and has been used for some time for tumors of the liver, prostate and kidney. In my practice, it is a standard option for fibroadenomas, which are bengin breast tumors. While cryoablation is still at this time considered to be experimental for breast cancer, a national trial which hopefully should complete enrollment sometime this year is showing promising results. In addition to destroying the tumor without surgery, some early studies have suggested that there is an immune response to the the ablated tumor - anti-tumor antibodies may form...could this be a type of auto-vaccine? Time will tell, but I am so excited about the possibility to have an option besides surgery for selected patients with early stage breast cancer! Here's a link with more information about the clinical trial: http://www.cancer.gov/clinicaltrials/search/view?cdrid=600976&version=Patient&protocolsearchid=5787655 Thanks for the question - cryoablation is fascinating technology, and involves freezing a lesion and then essentially letting nature run it's course. The freezing destroys the tumor cells, and the body then reabsorbs the dead cells. Cryoablation is not new technology, and has been used for some time for tumors of the liver, prostate and kidney. In my practice, it is a standard option for fibroadenomas, which are bengin breast tumors. While cryoablation is still at this time considered to be experimental for breast cancer, a national trial which hopefully should complete enrollment sometime this year is showing promising results. In addition to destroying the tumor without surgery, some early studies have suggested that there is an immune response to the the ablated tumor - anti-tumor antibodies may form...could this be a type of auto-vaccine? Time will tell, but I am so excited about the possibility to have an option besides surgery for selected patients with early stage breast cancer! Here's a link with more information about the clinical trial: http://www.cancer.gov/clinicaltrials/search/view?cdrid=600976&version=Patient&protocolsearchid=5787655

An excellent comprehensive answer. I'll just reinforce a few points - enlist an advocate, and ask questions. A new diagnosis of cancer or other serious illness is much too much for one person to handle alone, and you don't have to handle it alone! Write down your questions, and don't agree to any test, procedure, or treatment until you feel you've had a good explanation of why the test or treatment is necessary, and what the alternatives are. If you have been diagnosed with a serious illness, you might need time to absorb what the doctor has explained to you. For most of us, it is difficult to distill all of the information from a doctor even if the diagnosis is not serious.
Some good tips:
1. As your doctor for information on your diagnosis. He/she might have pamphlets for you to read. Ask for credible websites you can research yourself.
2. If you have not gotten all of your questions answered in the appointment with the doctor when you were given the diagnosis, make another appointment or possibly call him/her on the phone. Most doctors are not paid for phone calls so you might be better off seeing this doctor in person for a number of reasons.
3. Before that appointment, create a list of questions.
4. Get a notebook for these questions. You can do research on your diagnosis on credible websites only (websites ending in .edu, .gov or .org--medical academies, disease organizations, medical school websites, government websites) Bring that notebook with you to your appointment with the doctor and write down the answers to your questions.
5. Enlist an advocate. It's hard enough to deal with a new diagnosis much less remembering every detail of information. Your advocate can act as your second set of ears and eyes. She/he can even take notes for you in your doctor's appointment.
6. Gather copies of your medical records from the doctors you've seen that pertain to your current diagnosis. Make copies so you have a packet for each medical professional you see. This will also include your list of medications, dosages, allergies to medications, over-the-counter medications, herbs and supplements. If you see a new doctor or more than one specialist, you will need to present a complete picture to each professional. You cannot count on doctors and their offices to send copies of your medical records to other doctors. You cannot be sure that your doctors will talk to one another about your case. You must help facilitate this communication process. Ask your advocate to help you with this.
7. Get a second opinion from another specialist about your diagnosis and treatment plan, preferably a specialist affiliated with a highly respected medical school. This is not to doubt the first doctor's diagnosis, but to gather further information about your diagnosis, possible treatment plans,and more. You might find out there are alternative treatments you have not thought about. This is very important.
8. Create a support system. You will need a support system but if you have a spouse/partner and/or children, they will need support as well. For example, if you cannot drive your children to their after-school activities, who will? You can ask your advocate to help you with this.
9.Create a medical journal. Going through a serious illness requires a steep learning curve on your part and you will be learning new language and how to navigate a new world. Taking notes on new doctors, terminology, possible treatments, new research, possible medications and more, can help keep you organized, but more importantly, help you feel more in control of your medical care.
10. Get familiar with your health insurance plan. Find out what is covered by your plan and what isn't. Being prepared is so much easier now rather than later.
11. Research proposed treatment plans and weigh the benefits and risks of a treatment plan. Ask questions. Get educated on your disease. You'll be able to ask more effective questions but you'll also feel more empowered.

I agree with all the answers posted above! The reality is that each patient is different, the recovery time will vary tremendously depending on if reconstruction is performed or not, and if so, what type of reconstruction. General guidelines however are about 4-8 weeks to be back to full activity, again depending on what type of surgery is performed. Most patients are hospitalized for at least 24 hours, but again depending on the type of surgery and other factors (pain, nausea, etc), a 3-5 day hospital stay might be needed. On average drainage tubes are left in place for 7-10 days.

I would stress that many patients underestimate the time that will be needed for recovery - this is considered major surgery, and combined with the emotional stress of a new diagnosis of cancer, the best advice I can give is listen to your body and allow plenty of time for physical as well as emotional healing. Recovery can be different for all of us depending upon which method the mastectomy is performed and what type of reconstruction (if any) you are having. I had tissue expanders put in place at the time of my bi-lateral mastectomy, so I found them to be a bit uncomfortable. It felt as if I was wearing a very tight bra. It was difficult to find a comfortable position the first night, but by night 3 I was sleeping for 7 hours. By the 4th day I was sitting up with no problems- my chest was a bit sore, but not painful. I was off all meds (including Tylenol) a week after the surgery. Within 2 weeks I was sleeping on both sides without a problem. The only thing I had a problem with was getting back to my daily routine. I could go to work, but I couldn’t exercise! I needed to wait 3 months before I could get back on my horse or play tennis. My assumption is that one could get back to a milder form of exercise in a shorter amount of time. Again, you did not mention the type of reconstruction you are going to have, so I will just mention my experience. I have implants since I was not a candidate for any other type of surgery. What I love about my breasts now is that I do not have to wear a bra anymore (except for exercising) and of course they are exactly the same size and perfectly even. Downside is that since they are ‘fuller’ than a regular breast, you have a bit of ‘side boob’, which I don’t really like. I had skin sparing and nipple sparing surgery and the incisions were made right under my breasts, so you can’t even tell that I had surgery.
A friend of mine had a bi-lateral mastectomy a little over a year ago because of family history and being BRCA positive. She did not have cancer; she did it as a prophylactic measure. Interestingly enough, her roommate in the hospital was there for the very same reason.
Making the decision is a difficult one. I had a small cancer in one breast and a tiny one in the other. I chose a bi-lateral mastectomy over 2 lumpectomies for 2 reasons. I did not want to have radiation on both sides of my chest and I did not want to worry about a recurrence. It’s a difficult choice, especially with LCIS.
As I was told upon diagnosis, take a little time, collect all the information you can so you can feel comfortable with the decision you make. I wish you all the best.

There are several types of pain that can occur after axillary / underarm surgery either performed with lumpectomy or mastectomy. The most common situation is numbness of the upper inner arm, armpit area, and the side of the chest wall. This is related to cutting or injury to the intercostobrachial nerve, which runs from the chest wall to the arm and provides for sensation. However cutting the entire or at least part of the nerve is part of most axillary dissection surgeries, and often the nerve is not one large "trunk", but several small branches that cannot be seen. Damage to this nerve is less common with a sentinel node biopsy but can still occur. Some women will experience a hypersensitivity in the first few weeks or months after the surgery in which even the slightest touch to the skin will result in severe pain. This usually resolves within a few weeks to a few months at the most. The numbness may gradually resolve or at least improve over time but every patient is different and this is not predictable.

In a few cases, severe persistent pain will occur. This is not common, but when it is present, it can be very difficult to treat. Gabapentin (neurontin) is sometimes used, along with physical therapy, acupuncture, and other treatments. There are several types of pain that can occur after axillary / underarm surgery either performed with lumpectomy or mastectomy. The most common situation is numbness of the upper inner arm, armpit area, and the side of the chest wall. This is related to cutting or injury to the intercostobrachial nerve, which runs from the chest wall to the arm and provides for sensation. However cutting the entire or at least part of the nerve is part of most axillary dissection surgeries, and often the nerve is not one large "trunk", but several small branches that cannot be seen. Damage to this nerve is less common with a sentinel node biopsy but can still occur. Some women will experience a hypersensitivity in the first few weeks or months after the surgery in which even the slightest touch to the skin will result in severe pain. This usually resolves within a few weeks to a few months at the most. The numbness may gradually resolve or at least improve over time but every patient is different and this is not predictable.

In a few cases, severe persistent pain will occur. This is not common, but when it is present, it can be very difficult to treat. Gabapentin (neurontin) is sometimes used, along with physical therapy, acupuncture, and other treatments.

Thanks for the question! The San Antonio Breast Cancer Symposium is one of the largest and most prestigious breast cancer conferences, and often exciting and innovative research is presented. However at the recent meeting, a study was presented by a group from MD Anderson, questioning the safety and effectiveness of accelerated partial breast irradiation (APBI) for early-stage breast cancer - specifically they noted that patients undergoing this treatment have a higher rate of complications and eventual mastectomy. Unfortunately before the study was even presented, it received national media attention, leading to significant anxiety and confusion among women. This stresses the importance of reading the study, not just listening to the sound bite - here are some facts:
- The study used retrospective (after the fact) "claims data" to do their evaluation. That means they took Medicare billing information, not actual patient data, and drew some conclusions. It is NOT possible to accurately determine complication rates from claims data as they are not always reported. It is also not possible (and the authors admitted this) to determine why the women treated with APBI subsequently underwent mastectomy - it could have been for an entirely different cancer, even one in the other breast!
- The absolute increased risk of mastectomy was 1.8% which is quite low, and again we have no way to know why the women underwent mastectomy
- APBI has been the subject of multiple prospective (going-forward) and peer-reviewed studies, and has been shown to have an equivalent or in some cases better rate of breast cancer control compared to whole-breast irradiation; the complication rate is also equivalent.

3 respected professional medical societies published responses critical of the MD Anderson study, and I expect more criticism will come. The responses are from the American Society of Breast Surgeons: https://www.breastsurgeons.org/news/article.php?id=122, the American Brachytherapy Society: http://campaign.r20.constantcontact.com/render?llr=kdofiegab&v=001rj64Pj8NTf4ISgwN4cSdZYtZBR53GjAi73j4En_qeygPzWmSUe1qgGI7U-jt8HRV7NouL9sMViv1IOOeGT2QHMAaDWrfEuOApREAHj-8Z60%3D and the American Society for Radiation Oncology: https://astro.org/News-and-Media/News-Releases/2011/ASTRO--APBI-safe,-effective-for-some-breast-cancer-patients.aspx

It is again unfortunate that this poorly designed study with no real valid clinical data was allowed to be presented at such a prestigious meeting, and that it received immense national media attention before the scientific community was allowed to interpret the study and respond. I am hopeful that this will not happen in the future, as many women (and many physicians) were caused unnecessary anxiety regarding their breast cancer treatment options. Thanks for the question! The San Antonio Breast Cancer Symposium is one of the largest and most prestigious breast cancer conferences, and often exciting and innovative research is presented. However at the recent meeting, a study was presented by a group from MD Anderson, questioning the safety and effectiveness of accelerated partial breast irradiation (APBI) for early-stage breast cancer - specifically they noted that patients undergoing this treatment have a higher rate of complications and eventual mastectomy. Unfortunately before the study was even presented, it received national media attention, leading to significant anxiety and confusion among women. This stresses the importance of reading the study, not just listening to the sound bite - here are some facts:
- The study used retrospective (after the fact) "claims data" to do their evaluation. That means they took Medicare billing information, not actual patient data, and drew some conclusions. It is NOT possible to accurately determine complication rates from claims data as they are not always reported. It is also not possible (and the authors admitted this) to determine why the women treated with APBI subsequently underwent mastectomy - it could have been for an entirely different cancer, even one in the other breast!
- The absolute increased risk of mastectomy was 1.8% which is quite low, and again we have no way to know why the women underwent mastectomy
- APBI has been the subject of multiple prospective (going-forward) and peer-reviewed studies, and has been shown to have an equivalent or in some cases better rate of breast cancer control compared to whole-breast irradiation; the complication rate is also equivalent.

3 respected professional medical societies published responses critical of the MD Anderson study, and I expect more criticism will come. The responses are from the American Society of Breast Surgeons: https://www.breastsurgeons.org/news/article.php?id=122, the American Brachytherapy Society: http://campaign.r20.constantcontact.com/render?llr=kdofiegab&v=001rj64Pj8NTf4ISgwN4cSdZYtZBR53GjAi73j4En_qeygPzWmSUe1qgGI7U-jt8HRV7NouL9sMViv1IOOeGT2QHMAaDWrfEuOApREAHj-8Z60%3D and the American Society for Radiation Oncology: https://astro.org/News-and-Media/News-Releases/2011/ASTRO--APBI-safe,-effective-for-some-breast-cancer-patients.aspx

It is again unfortunate that this poorly designed study with no real valid clinical data was allowed to be presented at such a prestigious meeting, and that it received immense national media attention before the scientific community was allowed to interpret the study and respond. I am hopeful that this will not happen in the future, as many women (and many physicians) were caused unnecessary anxiety regarding their breast cancer treatment options.

Our patients have had a lot of success with Udderly Smooth cream - it comes in a big tub - good for elbows and feet, too! There are several skin care options. Some of the topical creams and lotions we recommend include Aquaphor, Biafine, Mederma, and Jean's Cream. We also recommend the use of Aloe Vera (plant or gel) or vitamin E cream. Much of this is individualistic and a matter of comfort.

The minimum amount of breast cancer that can be detected depends on what type of cancer you are dealing with. In terms of a lump or mass (usually representing an invasive ductal cancer), a tumor as small as 3-4 millimeters (25 millimeters = one inch, so 3-4 millimeters is well under 1/4 of an inch) can sometimes be seen on mammogram, ultrasound or MRI, depending on the density of the breast tissue. DCIS, or in-situ (or noninvasive) cancer often does not form a mass, and typically is detected when microcalcifications are seen on mammogram - again the amount of disease can range from just a few millimeters to a much larger area. Unfortunately both non-invasive and invasive cancers can be present without microcalcifications or a mass on imaging, so sometimes it is very difficult to get a true idea of the extent of disease before surgery. Once the tissue is removed, the pathologist will measure the size of the cancer - it may be larger or smaller than what was anticipated based on the imaging studies.

As far as the minimum amount of breast tissue removed at lumpectomy - it really varies tremendously - there is no standard. The goal of a lumpectomy is to remove the tumor and a "margin" - a rim of normal breast tissue - and still preserve as best possible the cosmetic appearance of the breast. There remains considerable debate on what an adequate margin is - some will be comfortable with no cancer cells right at the edge of the specimen, and some like to go for a wide margin, as large as one centimeter (10 millimeters) or greater. As in many areas, the truth is probably somewhere in between - usually 2-5 millimeters is generally acceptable for invasive cancer and 5 millimeters or greater for DCIS. But as I mentioned in the paragraph above, it can sometimes be difficult to estimate the true extent of the cancer, which makes it very difficult to give a good estimate prior to surgery of just how much tissue will be removed. In addition, at the time of surgery sometimes areas of adjacent tissue look or feel abnormal - it's sometimes a judgement call how much to remove. We try to balance between not having to return to the operating room due to positive margins, versus the poor cosmetic results of removing too much normal breast tissue.

There are some devices being evaluated that are looking at intraoperative margin assessment - being able to tell during the surgery if breast tissue at the edge of the tumor has cancer cells or not. These devices are under investigation, but do seem promising for providing the surgeon more information during the procedure regarding how much tissue to remove. The minimum amount of breast cancer that can be detected depends on what type of cancer you are dealing with. In terms of a lump or mass (usually representing an invasive ductal cancer), a tumor as small as 3-4 millimeters (25 millimeters = one inch, so 3-4 millimeters is well under 1/4 of an inch) can sometimes be seen on mammogram, ultrasound or MRI, depending on the density of the breast tissue. DCIS, or in-situ (or noninvasive) cancer often does not form a mass, and typically is detected when microcalcifications are seen on mammogram - again the amount of disease can range from just a few millimeters to a much larger area. Unfortunately both non-invasive and invasive cancers can be present without microcalcifications or a mass on imaging, so sometimes it is very difficult to get a true idea of the extent of disease before surgery. Once the tissue is removed, the pathologist will measure the size of the cancer - it may be larger or smaller than what was anticipated based on the imaging studies.

As far as the minimum amount of breast tissue removed at lumpectomy - it really varies tremendously - there is no standard. The goal of a lumpectomy is to remove the tumor and a "margin" - a rim of normal breast tissue - and still preserve as best possible the cosmetic appearance of the breast. There remains considerable debate on what an adequate margin is - some will be comfortable with no cancer cells right at the edge of the specimen, and some like to go for a wide margin, as large as one centimeter (10 millimeters) or greater. As in many areas, the truth is probably somewhere in between - usually 2-5 millimeters is generally acceptable for invasive cancer and 5 millimeters or greater for DCIS. But as I mentioned in the paragraph above, it can sometimes be difficult to estimate the true extent of the cancer, which makes it very difficult to give a good estimate prior to surgery of just how much tissue will be removed. In addition, at the time of surgery sometimes areas of adjacent tissue look or feel abnormal - it's sometimes a judgement call how much to remove. We try to balance between not having to return to the operating room due to positive margins, versus the poor cosmetic results of removing too much normal breast tissue.

There are some devices being evaluated that are looking at intraoperative margin assessment - being able to tell during the surgery if breast tissue at the edge of the tumor has cancer cells or not. These devices are under investigation, but do seem promising for providing the surgeon more information during the procedure regarding how much tissue to remove.

I agree with Dr. Feldman's answer - there is no question that complementary techniques can help put a patient in a better physical and mental state prior to undergoing therapy, and can help manage the side effects of therapy. Just as we have come to appreciate the importance of proper nutrition, exercise and sleep in the maintenance of health and prevention and treatment of disease, I think that CAM will also play an increasingly important role in disease prevention and treatment. The surgeon I used for my breast cancer was definitely not open to alternative methods. He would become somewhat irritated and angry at me when I didn't jump through the conventional hoops that he wanted me to. Every time I see him (which isn't often now) he also mentions how I didn't elect chemotherapy and the cancer can go to my brain, bones, lung-he never mentions how well I am doing even without the chemotherapy. But---when the last biopsy came back with no more cancer in my breast he also couldn't explain how that happened. Hopefully more surgeons will allow patients to make their own decisions and not chastise them for deciding on other options.

The following information is from the site Facing Our Risk: http://www.facingourrisk.org/index.php - a national nonprofit organization devoted to hereditary breast and ovarian cancer.

"Women with a BRCA mutation or other hereditary breast cancer who choose breast conservation to treat their breast cancer are at higher risk for another cancer in either breast than women with sporadic breast cancer. Although the exact risk depends on a woman’s age and other factors, one study found that BRCA carriers diagnosed with breast cancer have a 14% chance within ten years of developing the disease in the same breast, and a 37% chance within ten years of developing the disease in the opposite breast. Another study found a 40% chance for BRCA carriers to develop cancer in the opposite breast within ten years of their initial diagnosis. The risk for a second breast cancer among women who develop sporadic cancer is about 10%."


The following information is from the site Facing Our Risk: http://www.facingourrisk.org/index.php - a national nonprofit organization devoted to hereditary breast and ovarian cancer.

"Women with a BRCA mutation or other hereditary breast cancer who choose breast conservation to treat their breast cancer are at higher risk for another cancer in either breast than women with sporadic breast cancer. Although the exact risk depends on a woman’s age and other factors, one study found that BRCA carriers diagnosed with breast cancer have a 14% chance within ten years of developing the disease in the same breast, and a 37% chance within ten years of developing the disease in the opposite breast. Another study found a 40% chance for BRCA carriers to develop cancer in the opposite breast within ten years of their initial diagnosis. The risk for a second breast cancer among women who develop sporadic cancer is about 10%."

A properly performed nipple sparing mastectomy does appear to be a "safe" oncologic operation. Most commonly when a mastectomy is performed, the nipple and areola are removed. However given our more advanced imaging such as MRI, we are better able to determine the extent of disease prior to surgery (although no imaging study is perfect in this regard). For women with tumors away from the nipple/areolar complex, it may be reasonable to undergo a nipple sparing mastectomy with reconstruction. A properly performed nipple sparing mastectomy involves removing the majority if not all of the ductal tissue from within the nipple, to minimize the amount of tissue left behind at risk for breast cancer.

If you are interested in this approach, it is important to make sure your breast surgeon has experience with this procedure, as well as your reconstructive surgeon. It is also very important to realize that the nipple as well as the surrounding skin will almost always be numb after the surgery, and sensation may not ever return. Finally, depending on the natural breast shape and size and position of the nipple, a nipple-sparing approach may not provide the best cosmetic result. A properly performed nipple sparing mastectomy does appear to be a "safe" oncologic operation. Most commonly when a mastectomy is performed, the nipple and areola are removed. However given our more advanced imaging such as MRI, we are better able to determine the extent of disease prior to surgery (although no imaging study is perfect in this regard). For women with tumors away from the nipple/areolar complex, it may be reasonable to undergo a nipple sparing mastectomy with reconstruction. A properly performed nipple sparing mastectomy involves removing the majority if not all of the ductal tissue from within the nipple, to minimize the amount of tissue left behind at risk for breast cancer.

If you are interested in this approach, it is important to make sure your breast surgeon has experience with this procedure, as well as your reconstructive surgeon. It is also very important to realize that the nipple as well as the surrounding skin will almost always be numb after the surgery, and sensation may not ever return. Finally, depending on the natural breast shape and size and position of the nipple, a nipple-sparing approach may not provide the best cosmetic result.

I think this is a difficult choice for many women faced with this decision. Historically, mastectomy was the only operation available for breast cancer, and when the early clinical trials were conducted comparing mastectomy to lumpectomy, the surgeons and researchers faced a lot of criticism as it was a widely held belief that a radical operation was necessary if there was any chance of cure.

We now know thanks to that research, that there is no difference in the overall survival if a woman undergoes a mastectomy or a lumpectomy. However lumpectomy alone will result in a higher rate of the cancer returning in the breast, so radiation therapy after lumpectomy is necessary.

Absolute contraindications to breast conservation are multifocal cancer (cancer in multiple quadrants of the breast), inability to achieve an acceptable cosmetic result, and contraindications to radiation therapy (certain collagen-vascular diseases such as scleroderma). A history of prior radiation therapy to the breast is often a contraindication to breast conservation as well, but several clinical trials are examining the safety and effectiveness of limited radiation therapy in patients who have previously undergone whole-breast radiation.

Other than that, for most women with early-stage breast cancer, they do have choices. We tend to think having options is a good thing, but many women do struggle tremendously with this decision. I think this is a difficult choice for many women faced with this decision. Historically, mastectomy was the only operation available for breast cancer, and when the early clinical trials were conducted comparing mastectomy to lumpectomy, the surgeons and researchers faced a lot of criticism as it was a widely held belief that a radical operation was necessary if there was any chance of cure.

We now know thanks to that research, that there is no difference in the overall survival if a woman undergoes a mastectomy or a lumpectomy. However lumpectomy alone will result in a higher rate of the cancer returning in the breast, so radiation therapy after lumpectomy is necessary.

Absolute contraindications to breast conservation are multifocal cancer (cancer in multiple quadrants of the breast), inability to achieve an acceptable cosmetic result, and contraindications to radiation therapy (certain collagen-vascular diseases such as scleroderma). A history of prior radiation therapy to the breast is often a contraindication to breast conservation as well, but several clinical trials are examining the safety and effectiveness of limited radiation therapy in patients who have previously undergone whole-breast radiation.

Other than that, for most women with early-stage breast cancer, they do have choices. We tend to think having options is a good thing, but many women do struggle tremendously with this decision.

The term "lifestyle modifications" means many things, and I'll try to elaborate. Just as we all learn (often the hard way) that the secret to weight loss is no secret at all, it's old fashioned diet and exercise, the same can be said with other areas of health maintenance and disease prevention. We're learning more every day about the effects of obesity, processed food diets, lack of sleep, chronic stress, and other realities of modern living in terms of their contribution to many diseases as well as cancer. Not all diseases and cancer can be prevented by a healthy lifestyle, but here are some facts:

- postmenopausal women who are overweight have a higher risk of developing breast cancer, and if they've been treated for breast cancer, their risk of recurrence is increased if they are overweight
- moderate exercise has been shown to reduce the risk of breast cancer development as well as the risk of recurrent disease
- a high fat diet has been linked to an increased risk of breast cancer
- more than one alcoholic drink per day (in women) is associated with an increasing risk of breast cancer
the list goes on and on...


But I think we also do our patients a disservice by harping too much on these studies, because many then will feel that they brought the cancer (or other disease) on themselves by not controlling their diet, activity level, or stress. The reality is that breast cancer and many other diseases are caused and exacerbated by multiple factors - this is why studies looking at preventative methods are so difficult. And it's also why the studies that pop up every so often regarding the benefits of a particular nutrient or extract need to be placed in proper perspective - it's usually not as simple as one nutrient or extract.


My recommendation for all of my patients, not just those with breast cancer, is to take care of themselves. As we get older, our bodies become less tolerant to the effects of lack of sleep, heavy alcohol intake, and the dietary habits that we had when we were in our 20's. Our bodies have changed - we have to change our habits if we want to try to stay healthy. So the basics:

- Low fat (not no fat!!) diet - focus on the healthy fats such as olive oil, salmon, walnuts, avocado
- Plant-based diet - focus on lots of greens and veggies of all colors, as well as fruits. You may feel it's easier to take your fruits and veggies in pill form, but while you may be getting some of the vitamins and extracts, the way the real foods interact is very complex (just like how cancer develops) and cannot be replicated in a pill. Trace nutrients that we may not even know about will also be missing, as well as fiber, not to mention the wonderful taste of properly prepared, fresh vegetables!
- Animal protein is ok, just consider the source and eat in moderation
- Don't forget non-animal sources of protein such as legumes, beans, and quinoa
- Moderation in alcohol intake - 0-1 per day
- Moderate exercise - it's ok if you can't do you spinning class like you did 10 years ago - a good 30 minute walk once a day is fine! If you need that endorphin rush of spinning or other strenuous activity, make sure to balance it with some more meditative exercise such as yoga or pilates
- Proper sleep - we all need 7-9 hours a night, period. Our bodies repair themselves during sleep, and you can't just "catch up" on the weekends. Those that catch me on-line after 10pm pacific time - feel free to call me out on this one!
- Meditation / Reflection - so very important to take some time each day to reflect on what is good in your life - having a sense of appreciation and gratitude for the good things will help make it easier to get through the tough times. This can be as formal or informal as you want, it's just important to fit this in somewhere.


Those are the basics - we could go on for hours, and I'd welcome comments and suggestions from others on these points. Just remember that you're not doing this specifically for breast cancer prevention - these are steps to make you a healthier and happier person. The term "lifestyle modifications" means many things, and I'll try to elaborate. Just as we all learn (often the hard way) that the secret to weight loss is no secret at all, it's old fashioned diet and exercise, the same can be said with other areas of health maintenance and disease prevention. We're learning more every day about the effects of obesity, processed food diets, lack of sleep, chronic stress, and other realities of modern living in terms of their contribution to many diseases as well as cancer. Not all diseases and cancer can be prevented by a healthy lifestyle, but here are some facts:

- postmenopausal women who are overweight have a higher risk of developing breast cancer, and if they've been treated for breast cancer, their risk of recurrence is increased if they are overweight
- moderate exercise has been shown to reduce the risk of breast cancer development as well as the risk of recurrent disease
- a high fat diet has been linked to an increased risk of breast cancer
- more than one alcoholic drink per day (in women) is associated with an increasing risk of breast cancer
the list goes on and on...


But I think we also do our patients a disservice by harping too much on these studies, because many then will feel that they brought the cancer (or other disease) on themselves by not controlling their diet, activity level, or stress. The reality is that breast cancer and many other diseases are caused and exacerbated by multiple factors - this is why studies looking at preventative methods are so difficult. And it's also why the studies that pop up every so often regarding the benefits of a particular nutrient or extract need to be placed in proper perspective - it's usually not as simple as one nutrient or extract.


My recommendation for all of my patients, not just those with breast cancer, is to take care of themselves. As we get older, our bodies become less tolerant to the effects of lack of sleep, heavy alcohol intake, and the dietary habits that we had when we were in our 20's. Our bodies have changed - we have to change our habits if we want to try to stay healthy. So the basics:

- Low fat (not no fat!!) diet - focus on the healthy fats such as olive oil, salmon, walnuts, avocado
- Plant-based diet - focus on lots of greens and veggies of all colors, as well as fruits. You may feel it's easier to take your fruits and veggies in pill form, but while you may be getting some of the vitamins and extracts, the way the real foods interact is very complex (just like how cancer develops) and cannot be replicated in a pill. Trace nutrients that we may not even know about will also be missing, as well as fiber, not to mention the wonderful taste of properly prepared, fresh vegetables!
- Animal protein is ok, just consider the source and eat in moderation
- Don't forget non-animal sources of protein such as legumes, beans, and quinoa
- Moderation in alcohol intake - 0-1 per day
- Moderate exercise - it's ok if you can't do you spinning class like you did 10 years ago - a good 30 minute walk once a day is fine! If you need that endorphin rush of spinning or other strenuous activity, make sure to balance it with some more meditative exercise such as yoga or pilates
- Proper sleep - we all need 7-9 hours a night, period. Our bodies repair themselves during sleep, and you can't just "catch up" on the weekends. Those that catch me on-line after 10pm pacific time - feel free to call me out on this one!
- Meditation / Reflection - so very important to take some time each day to reflect on what is good in your life - having a sense of appreciation and gratitude for the good things will help make it easier to get through the tough times. This can be as formal or informal as you want, it's just important to fit this in somewhere.


Those are the basics - we could go on for hours, and I'd welcome comments and suggestions from others on these points. Just remember that you're not doing this specifically for breast cancer prevention - these are steps to make you a healthier and happier person.

Thanks for the question, Debbie! Cryoablation is a fascinating technology when applied to breast lesions, and one that I've been involved with for almost 10 years. Cryoablation refers to a technique where the tumor is frozen "in-situ" (within the breast); the body then reabsorbs the tumor and surgery is not required. It is a standard (and FDA-cleared) treatment in my practice for benign breast tumors (fibroadenomas) and is performed in the office under local anesthesia using just a very small skin nick instead of a surgery which will leave a larger scar and has the potential for some change in the shape or size of the breast.

For breast cancers, there are several small studies suggesting that cryoablation treatment is effective. The American College of Surgeons Oncology Group has a national clinical trial evaluating cryoablation for the treatment of breast cancer - once this study is complete, we should have more information regarding how effective cryoablation will be for breast cancers, but it does appear to be a promising technology and may allow some women in the future to be treated for their breast cancer by undergoing a minimally-invasive, office based procedure. We're hoping for results from the trial within about a year.

For general information about cryoablation for breast lesions:
http://www.cfbci.com/cryoablation.html

For information regarding the ACOSOG Z1072 clinical trial:
http://clinicaltrials.gov/ct2/show/NCT00723294?term=ACOSOG+Z1072&rank=1

For a video of the procedure and more information:
http://www.youtube.com/user/dattaimd?feature=mhum#p/a/u/0/m40h23h-FcA
Thanks for the question, Debbie! Cryoablation is a fascinating technology when applied to breast lesions, and one that I've been involved with for almost 10 years. Cryoablation refers to a technique where the tumor is frozen "in-situ" (within the breast); the body then reabsorbs the tumor and surgery is not required. It is a standard (and FDA-cleared) treatment in my practice for benign breast tumors (fibroadenomas) and is performed in the office under local anesthesia using just a very small skin nick instead of a surgery which will leave a larger scar and has the potential for some change in the shape or size of the breast.

For breast cancers, there are several small studies suggesting that cryoablation treatment is effective. The American College of Surgeons Oncology Group has a national clinical trial evaluating cryoablation for the treatment of breast cancer - once this study is complete, we should have more information regarding how effective cryoablation will be for breast cancers, but it does appear to be a promising technology and may allow some women in the future to be treated for their breast cancer by undergoing a minimally-invasive, office based procedure. We're hoping for results from the trial within about a year.

For general information about cryoablation for breast lesions:
http://www.cfbci.com/cryoablation.html

For information regarding the ACOSOG Z1072 clinical trial:
http://clinicaltrials.gov/ct2/show/NCT00723294?term=ACOSOG+Z1072&rank=1

For a video of the procedure and more information:
http://www.youtube.com/user/dattaimd?feature=mhum#p/a/u/0/m40h23h-FcA

The first thing to realize, is that the term "biopsy" often means different things to different people, so hopefully I can provide some clarification as well as some advice to women who might be in this situation.

It used to be that when a woman felt a lump in her breast, she was given one option - surgery. The lump was removed, and depending on the results she either was told to resume routine follow up (if it was benign) or had a mastectomy (if it was cancer) - women used to sign a consent form that would allow for lump removal and mastectomy all at the same time if the pathology showed that it was cancer. At the time, we did not have the sophisticated imaging and biopsy devices that we do now, and there was only one operation for breast cancer - a radical or modified radical mastectomy.

Thankfully, a lot has changed. Our imaging has significantly improved - ultrasound can be invaluable when dealing with a palpable lump, especially in a young woman, as often we can make the distinction between normal "lumpy" breast tissue, a fluid-filled cyst, or a solid mass. In addition, ultrasound can give us some idea based on the characteristics of the lesion whether a solid mass is benign or malignant, but ultrasound and any imaging test does not take the place of obtaining a tissue sample that the pathologist can review to make a definitive diagnosis.

The standard of care is that minimally-invasive, image-guided biopsies be performed to make a diagnosis, not surgical removal. There are a few situations when image-guided biopsies are not technically possible or are not appropriate, but they can be performed in the majority of cases. If the biopsy demonstrates a benign lesion, the patient may not need surgery at all, or may be a candidate for a minimally invasive method of treatment, such as cryoablation (see my answer on cryoablation for more details). Approximately 80-85% of biopsies result in a benign diagnosis, and we try to reserve the operating room for therapy, not diagnosis.

If the lesion is found to be malignant, further workup such as MRI or other testing might appropriate in order to properly plan the surgery. There are also plenty of studies demonstrating that if surgery is the first procedure performed in the setting of breast cancer, the woman is more likely to require more than one operation either due to positive margins, the need for lymph node biopsy, or other factors. A more appropriate and more cosmetic procedure will be done if the diagnosis is established prior to surgery. This is supported by the American Society of Breast Surgeons (http://www.breastsurgeons.org/statements/PDF_Statements/Percutaneous_Needle_Biopsy.pdf)


As to who should perform the biopsy, surgeon or radiologist - it depends on the individual practice situation and training of the physician. More surgeons are being trained in performance of ultrasound, ultrasound-guided biopsy, and stereotactic (mammogram-guided) biopsy, and the American Society of Breast Surgeons has education, certification and accreditation programs specifically for surgeons. As a surgeon, I would rather perform the imaging and biopsy myself, as I will then have a better appreciation for exactly where the lesion is (more important when dealing with non-palpable lesions), especially if surgery is eventually required. However radiologists do perform the imaging and biopsies as well, and in many situations, work collaboratively with the surgeon.

However the most important point is not necessarily who performs the biopsy (assuming that anyone performing it is qualified), but that whenever possible, a minimally-invasive needle biopsy be performed rather than surgery as the initial procedure. The first thing to realize, is that the term "biopsy" often means different things to different people, so hopefully I can provide some clarification as well as some advice to women who might be in this situation.

It used to be that when a woman felt a lump in her breast, she was given one option - surgery. The lump was removed, and depending on the results she either was told to resume routine follow up (if it was benign) or had a mastectomy (if it was cancer) - women used to sign a consent form that would allow for lump removal and mastectomy all at the same time if the pathology showed that it was cancer. At the time, we did not have the sophisticated imaging and biopsy devices that we do now, and there was only one operation for breast cancer - a radical or modified radical mastectomy.

Thankfully, a lot has changed. Our imaging has significantly improved - ultrasound can be invaluable when dealing with a palpable lump, especially in a young woman, as often we can make the distinction between normal "lumpy" breast tissue, a fluid-filled cyst, or a solid mass. In addition, ultrasound can give us some idea based on the characteristics of the lesion whether a solid mass is benign or malignant, but ultrasound and any imaging test does not take the place of obtaining a tissue sample that the pathologist can review to make a definitive diagnosis.

The standard of care is that minimally-invasive, image-guided biopsies be performed to make a diagnosis, not surgical removal. There are a few situations when image-guided biopsies are not technically possible or are not appropriate, but they can be performed in the majority of cases. If the biopsy demonstrates a benign lesion, the patient may not need surgery at all, or may be a candidate for a minimally invasive method of treatment, such as cryoablation (see my answer on cryoablation for more details). Approximately 80-85% of biopsies result in a benign diagnosis, and we try to reserve the operating room for therapy, not diagnosis.

If the lesion is found to be malignant, further workup such as MRI or other testing might appropriate in order to properly plan the surgery. There are also plenty of studies demonstrating that if surgery is the first procedure performed in the setting of breast cancer, the woman is more likely to require more than one operation either due to positive margins, the need for lymph node biopsy, or other factors. A more appropriate and more cosmetic procedure will be done if the diagnosis is established prior to surgery. This is supported by the American Society of Breast Surgeons (http://www.breastsurgeons.org/statements/PDF_Statements/Percutaneous_Needle_Biopsy.pdf)


As to who should perform the biopsy, surgeon or radiologist - it depends on the individual practice situation and training of the physician. More surgeons are being trained in performance of ultrasound, ultrasound-guided biopsy, and stereotactic (mammogram-guided) biopsy, and the American Society of Breast Surgeons has education, certification and accreditation programs specifically for surgeons. As a surgeon, I would rather perform the imaging and biopsy myself, as I will then have a better appreciation for exactly where the lesion is (more important when dealing with non-palpable lesions), especially if surgery is eventually required. However radiologists do perform the imaging and biopsies as well, and in many situations, work collaboratively with the surgeon.

However the most important point is not necessarily who performs the biopsy (assuming that anyone performing it is qualified), but that whenever possible, a minimally-invasive needle biopsy be performed rather than surgery as the initial procedure.

Thanks for your question - it is difficult to determine if any physician is "good", just like any other professional whose services you rely on - attorney, accountant, car mechanic...

The obvious initial things to check are board certification, and training location such as medical school and residency. Professional society memberships usually indicate an interest in staying current and following the latest treatment recommendations. Some professional societies relevant to breast surgeons are the American Society of Breast Surgeons (http://breastsurgeons.org/) the American Society of Breast Disease (http://www.asbd.org/) and the Society of Surgical Oncology (http://www.surgonc.org/).

Publications and research are important, but realize that many excellent community / private practice surgeons stay current and practice state of the art care by reading the literature and attending meetings but may not have the time or resources to be involved with research themselves.

Referrals from a good, engaged primary care physician should count for a lot - if that primary care physician is working closely with his or her patients, they will have feedback from their patients regarding the surgeon's personality, practice style, and of course results.

Talk to other patients, local hospital (and operating room) nurses. Many hospitals have a "doctor finder" physician referral service - it can be a good start. Talk to the mammographer or nurse navigator at the breast center where you get your mammograms done, or talk to the mammography technologist - these women see patients back from all the surgeons and often hear the good and bad stories. There are a tremendous number of on-line patient resources as well - as just one example, http://www.savisisters.com/about-savi is an on-line resource and support site for all women with breast cancer, but it focuses on women who are undergoing 5-day partial breast irradiation - patients have the opportunity to talk to other patients who have "been there, done that" and get some feedback.

Also ask your surgeon - "do you have any patients with my similar type of tumor/proposed surgery, etc that I can talk to to get their experience?". Very reasonable question.

At the end of the day, you have to make a decision and it can be overwhelming especially if you've received input from multiple sources. Interview all the doctors, and keep an open mind. Take notes, and bring someone with you who can help ask questions but also be an objective observer. After you've received your opinions, review them just like you'd review any other important proposals. And don't hesitate to call or return for a follow up visit to get clarification on issues to help finalize your decision.

Thanks for your question - it is difficult to determine if any physician is "good", just like any other professional whose services you rely on - attorney, accountant, car mechanic...

The obvious initial things to check are board certification, and training location such as medical school and residency. Professional society memberships usually indicate an interest in staying current and following the latest treatment recommendations. Some professional societies relevant to breast surgeons are the American Society of Breast Surgeons (http://breastsurgeons.org/) the American Society of Breast Disease (http://www.asbd.org/) and the Society of Surgical Oncology (http://www.surgonc.org/).

Publications and research are important, but realize that many excellent community / private practice surgeons stay current and practice state of the art care by reading the literature and attending meetings but may not have the time or resources to be involved with research themselves.

Referrals from a good, engaged primary care physician should count for a lot - if that primary care physician is working closely with his or her patients, they will have feedback from their patients regarding the surgeon's personality, practice style, and of course results.

Talk to other patients, local hospital (and operating room) nurses. Many hospitals have a "doctor finder" physician referral service - it can be a good start. Talk to the mammographer or nurse navigator at the breast center where you get your mammograms done, or talk to the mammography technologist - these women see patients back from all the surgeons and often hear the good and bad stories. There are a tremendous number of on-line patient resources as well - as just one example, http://www.savisisters.com/about-savi is an on-line resource and support site for all women with breast cancer, but it focuses on women who are undergoing 5-day partial breast irradiation - patients have the opportunity to talk to other patients who have "been there, done that" and get some feedback.

Also ask your surgeon - "do you have any patients with my similar type of tumor/proposed surgery, etc that I can talk to to get their experience?". Very reasonable question.

At the end of the day, you have to make a decision and it can be overwhelming especially if you've received input from multiple sources. Interview all the doctors, and keep an open mind. Take notes, and bring someone with you who can help ask questions but also be an objective observer. After you've received your opinions, review them just like you'd review any other important proposals. And don't hesitate to call or return for a follow up visit to get clarification on issues to help finalize your decision.

It is a big surgery, no doubt. There are generally several options for immediate reconstruction after mastectomy is performed.

One is placement of tissue expanders - temporary implants that are placed below the muscle at the time of mastectomy, and then are gradually "inflated" to the proper size; they are then exchanged for the "permanent" implants in a 2nd operation. Occasionally the "permanent" implants can be placed at the time of mastectomy but this is less common. I say "permanent" as none of these devices are meant to last forever; revisions and replacements may be needed.

The other option is autologous tissue (your own native tissue) using some sort of flap - latissimus (back muscle) and TRAM (abdominal muscle) are examples of so-called pedicled flaps, in which the muscle and skin are rotated from the donor site to recreate a breast mound, leaving the blood vessels from the muscle and skin attached. Free flaps such as the DIEP and others, involve a complete removal of the skin and fat and sometimes some muscle from the donor site, and the blood vessels from this tissue are sewn to the blood vessels in the chest area.

One type of reconstruction is not necessarily "better" than another - recovery tends to be longer with autologous tissue flaps but the cosmetic results in some patients may be better with native tissue compared to implants. Some women that are undergoing bilateral mastectomy do not have enough native tissue to re-create a breast mound so implants might be the better option in this situation.

The decision for which procedure to undergo is really an individual one depending on the possible need for radiation therapy after surgery, your skin and muscle condition and the amount of tissue available for transfer based on your body habitus and desired reconstruction shape and size. Consultation with one or more plastic surgeons who are experienced in breast reconstruction is generally advised so that you can get information specific to your case, which should help you make the best decision for your situation. It is a big surgery, no doubt. There are generally several options for immediate reconstruction after mastectomy is performed.

One is placement of tissue expanders - temporary implants that are placed below the muscle at the time of mastectomy, and then are gradually "inflated" to the proper size; they are then exchanged for the "permanent" implants in a 2nd operation. Occasionally the "permanent" implants can be placed at the time of mastectomy but this is less common. I say "permanent" as none of these devices are meant to last forever; revisions and replacements may be needed.

The other option is autologous tissue (your own native tissue) using some sort of flap - latissimus (back muscle) and TRAM (abdominal muscle) are examples of so-called pedicled flaps, in which the muscle and skin are rotated from the donor site to recreate a breast mound, leaving the blood vessels from the muscle and skin attached. Free flaps such as the DIEP and others, involve a complete removal of the skin and fat and sometimes some muscle from the donor site, and the blood vessels from this tissue are sewn to the blood vessels in the chest area.

One type of reconstruction is not necessarily "better" than another - recovery tends to be longer with autologous tissue flaps but the cosmetic results in some patients may be better with native tissue compared to implants. Some women that are undergoing bilateral mastectomy do not have enough native tissue to re-create a breast mound so implants might be the better option in this situation.

The decision for which procedure to undergo is really an individual one depending on the possible need for radiation therapy after surgery, your skin and muscle condition and the amount of tissue available for transfer based on your body habitus and desired reconstruction shape and size. Consultation with one or more plastic surgeons who are experienced in breast reconstruction is generally advised so that you can get information specific to your case, which should help you make the best decision for your situation.

Ok, the first question that I have for you - a non-invasive cancer is DCIS, which is pTis - T1 and T2 refer to the size of invasive cancer. I'm assuming that you had a 3cm invasive cancer with associated DCIS? Please respond and I'll be happy to follow up later with more information. Ok, the first question that I have for you - a non-invasive cancer is DCIS, which is pTis - T1 and T2 refer to the size of invasive cancer. I'm assuming that you had a 3cm invasive cancer with associated DCIS? Please respond and I'll be happy to follow up later with more information.

That's a good question, especially with all the information we now have linking breast density to an increased risk of breast cancer. Density refers to relative proportion of fibrous or glandular tissue to fatty tissue in the breast and is most commonly evaluated by appearance of the tissue on mammogram. Dense tissue is not the same as "lumpiness" - a woman can have a lot of lumpy breast tissue but the tissue could be primarily fat. In general, breast density does decrease with age - the normal aging process makes the breast tissue more fatty over time. This results in easier interpretation of mammograms and other imaging studies as women get older as it is harder to "see through" the dense breast tissue on mammogram to identify tumors - this is a major reason why mammograms and even ultrasound and MRI have a harder time detecting breast cancer in younger women.

Breast density is not only influenced by age however. Women that are on hormone replacement therapy will generally continue to have dense breast tissue even after menopause, and some women even without HRT have dense breast tissue - genetics, body weight, diet, activity and other factors probably play a role as well.

It is important to know that your risk of breast cancer is increased if you have dense breast tissue, but the majority of young women DO have dense breast tissue. Density is reported on your mammogram report, but often only on the report that goes to the physician, not the "layperson letter" that you would receive. Several states have either passed legislation or have legislation pending that would require mammogram facilities to inform women of their breast density. It is reasonable to ASK your physician or mammographer about your breast density so that you are informed. Depending on your risk factors, additional testing such as ultrasound and MRI might be recommended, but they are currently not recommended for all women with dense breast tissue. However, this field is changing, so stay tuned!

That's a good question, especially with all the information we now have linking breast density to an increased risk of breast cancer. Density refers to relative proportion of fibrous or glandular tissue to fatty tissue in the breast and is most commonly evaluated by appearance of the tissue on mammogram. Dense tissue is not the same as "lumpiness" - a woman can have a lot of lumpy breast tissue but the tissue could be primarily fat. In general, breast density does decrease with age - the normal aging process makes the breast tissue more fatty over time. This results in easier interpretation of mammograms and other imaging studies as women get older as it is harder to "see through" the dense breast tissue on mammogram to identify tumors - this is a major reason why mammograms and even ultrasound and MRI have a harder time detecting breast cancer in younger women.

Breast density is not only influenced by age however. Women that are on hormone replacement therapy will generally continue to have dense breast tissue even after menopause, and some women even without HRT have dense breast tissue - genetics, body weight, diet, activity and other factors probably play a role as well.

It is important to know that your risk of breast cancer is increased if you have dense breast tissue, but the majority of young women DO have dense breast tissue. Density is reported on your mammogram report, but often only on the report that goes to the physician, not the "layperson letter" that you would receive. Several states have either passed legislation or have legislation pending that would require mammogram facilities to inform women of their breast density. It is reasonable to ASK your physician or mammographer about your breast density so that you are informed. Depending on your risk factors, additional testing such as ultrasound and MRI might be recommended, but they are currently not recommended for all women with dense breast tissue. However, this field is changing, so stay tuned!

I agree with all the responses so far - and will reinforce that this is the time to take a few steps back, breathe, and consider all of your options. A prophylactic mastectomy (removal of the unaffected breast) will not improve your overall survival from breast cancer, and if you have an estrogen-receptor positive ("ER positive") tumor and are placed on tamoxifen or an aromatase inhibitor after surgery, these medications will reduce the risk of a new cancer developing in the healthy breast. Women who test positive for a BRCA mutation have a much higher risk for developing a new cancer which is why bilateral mastectomy is often recommended or at least discussed. In the absence of a BRCA or other gene mutation however, prophylactic mastectomy while an option, is often not a recommendation. Again, take your time with your decision, and consider all of your options. My heart goes out to you. What a tough, tough day it must be for you. I remember walking around in a shocked limbo state for a few days.

I was diagnosed with a grade 3/stage 1 tumour in October of 2009. Given my age (30) and my BRCA1 gene mutation, my doctors recommended that I start with a lumpectomy and four rounds of chemotherapy, but also suggested a follow up bilateral mastectomy and reconstruction as a precaution against a second breast cancer diagnosis (either in the same or the other breast). All of this being said, my aunt who has the same genetic mutation had breast cancer (stage 2) 18 years ago and opted to have a lumpectomy instead of a mastectomy. She still gets screened regularly, but has been cancer free ever since. It was not an easy decision, but I went through the double mastectomy in May of 2010 and had my final stage of the reconstruction in January of this year. I won't lie and tell you it was easy (physically or emotionally), but I am so relieved to never have to get another mammogram or MRI again. The results don't look as good as I imagined, but I am alive and cancer free. For this, I will always be grateful.

Know that there is no right answer because what might be right for me; might not be right for you. Although so many of us have been through breast cancer, we all have a unique story. Thank you for reaching out to the community and please let me know if you have any follow up questions or just need an ear. Big hugs, Terri

Dense breast tissue causes 2 problems - one is that it is now known that women with dense breast tissue have a higher rate of developing breast cancer, and the second is that breast cancer is harder to detect in women with dense breast tissue. Mammograms will miss 10-20% of breast cancers, more often in women with dense breast tissue. Ultrasound and MRI examinations can be performed in addition to a mammogram, but no test is 100% sensitive and specific for diagnosing breast cancer. Ultrasound and MRI are also more difficult to interpret in women with dense breast tissue, just like mammograms. MRI in particular also has a relatively high (up to 20%) false positive rate - it will often show things that look suspicious and require further investigation and sometimes biopsy, and the finding then turns out to be normal - these are some of the reasons that MRI is not recommended as a general screening test for all women, but rather is recommended for use in specific situations.

I do feel that women should know their breast density - "lumpiness" on exam is not the same as dense breast tissue. This information is generally included in the formal mammogram report provided to the ordering physician, but is not required to be included in the "lay letter" - the letter that gets sent to the patient (the wording of the reports and the lay letter is regulated by the FDA under the Mammography Quality Standards Act: http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActandProgram/Regulations/ucm110906.htm#s9004

Connecticut and Rhode Island have passed legislation requiring that the patient be informed of her breast density, and this is pending in California as well.

There are no uniform recommendations for how to provide increased screening to women with dense breast tissue, but at the very least, make sure that when you get your mammogram, you get a newer digital mammogram, rather than an older, film-screen - you just need to ask the facility and they will let you know. The use of ultrasound and MRI should be discussed with your physician or breast specialist and will take into account your family history and other breast cancer risk factors as well as breast density.
Dense breast tissue causes 2 problems - one is that it is now known that women with dense breast tissue have a higher rate of developing breast cancer, and the second is that breast cancer is harder to detect in women with dense breast tissue. Mammograms will miss 10-20% of breast cancers, more often in women with dense breast tissue. Ultrasound and MRI examinations can be performed in addition to a mammogram, but no test is 100% sensitive and specific for diagnosing breast cancer. Ultrasound and MRI are also more difficult to interpret in women with dense breast tissue, just like mammograms. MRI in particular also has a relatively high (up to 20%) false positive rate - it will often show things that look suspicious and require further investigation and sometimes biopsy, and the finding then turns out to be normal - these are some of the reasons that MRI is not recommended as a general screening test for all women, but rather is recommended for use in specific situations.

I do feel that women should know their breast density - "lumpiness" on exam is not the same as dense breast tissue. This information is generally included in the formal mammogram report provided to the ordering physician, but is not required to be included in the "lay letter" - the letter that gets sent to the patient (the wording of the reports and the lay letter is regulated by the FDA under the Mammography Quality Standards Act: http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActandProgram/Regulations/ucm110906.htm#s9004

Connecticut and Rhode Island have passed legislation requiring that the patient be informed of her breast density, and this is pending in California as well.

There are no uniform recommendations for how to provide increased screening to women with dense breast tissue, but at the very least, make sure that when you get your mammogram, you get a newer digital mammogram, rather than an older, film-screen - you just need to ask the facility and they will let you know. The use of ultrasound and MRI should be discussed with your physician or breast specialist and will take into account your family history and other breast cancer risk factors as well as breast density.

Dense breast tissue causes 2 problems - one is that it is now known that women with dense breast tissue have a higher rate of developing breast cancer, and the second is that breast cancer is harder to detect in women with dense breast tissue. Mammograms will miss 10-20% of breast cancers, more often in women with dense breast tissue. Ultrasound and MRI examinations can be performed in addition to a mammogram, but no test is 100% sensitive and specific for diagnosing breast cancer. Ultrasound and MRI are also more difficult to interpret in women with dense breast tissue, just like mammograms. MRI in particular also has a relatively high (up to 20%) false positive rate - it will often show things that look suspicious and require further investigation and sometimes biopsy, and the finding then turns out to be normal - these are some of the reasons that MRI is not recommended as a general screening test for all women, but rather is recommended for use in specific situations.

I do feel that women should know their breast density - "lumpiness" on exam is not the same as dense breast tissue. This information is generally included in the formal mammogram report provided to the ordering physician, but is not required to be included in the "lay letter" - the letter that gets sent to the patient (the wording of the reports and the lay letter is regulated by the FDA under the Mammography Quality Standards Act: http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActandProgram/Regulations/ucm110906.htm#s9004

Connecticut and Rhode Island have passed legislation requiring that the patient be informed of her breast density, and this is pending in California as well.

There are no uniform recommendations for how to provide increased screening to women with dense breast tissue, but at the very least, make sure that when you get your mammogram, you get a newer digital mammogram, rather than an older, film-screen - you just need to ask the facility and they will let you know. The use of ultrasound and MRI should be discussed with your physician or breast specialist and will take into account your family history and other breast cancer risk factors as well as breast density. As usual, Dr. Attai you have a great answer. Question: How do we get other states to get on board with legislation requiring the patient to be informed of her breast density? Would you know?

My gynecologist(s)- I've had a number NEVER told me that because I had dense breasts I should have further testing beyond a mammogram, and the ultrasound (my decision to get one) was what picked up the cancer, NOT the mammogram. Obviously this is upsetting because my cancer could have been picked up at stage 1 instead of stage 4. The difference between life and death, literallly.

The following information is a good summary of tumor grade, taken from http://www.cancerfacts.com/DefaultSecure.asp "Tumor grade (G) is an evaluation of how abnormal a cancer cell is compared to the normal cells from which it arises. This evaluation is called the "histologic tumor grade" and is done by the pathologist when examining the biopsy specimen. Histology is the study of the microscopic structure of the cells, which helps to predict how the cancer will behave. An objective score is given to each of three structural features of the tumor. A score of 1 (the most favorable) to 3 (the least favorable) is given for each feature.

The total score determines the tumor grade. This system describes the cell in terms of how well the cancer cell resembles the normal cell from which it arises. If the cancer cell looks very much like a normal breast cell, then it is called "well-differentiated". If the cancer cell poorly resembles a normal breast cell or not at all, then it is called "poorly differentiated or undifferentiated".

GX: grade cannot be assessed, undetermined grade
G1: well differentiated (low grade) This is the most favorable grade and reflects a total score of 3-5
G2: moderately differentiated (intermediate grade) This reflects a score of 6-7
G3: poorly differentiated (high grade) This is the least favorable grade, with a score of 8-9

Different systems are used to categorize the histologic (referring to tissue) tumor grade. The NCCN currently recommends using The Nottingham combined system for grading tumors. Another classification system is the Bloom-Richardson Score. The systems are similar: the higher the score, the less favorable the tumor.

The tumor grade can influence treatment decisions, especially if additional treatment such as chemotherapy or hormone therapy is needed after surgery."

It is important to note the difference between tumor GRADE, which as described above comments on the individual cancer cell, and tumor STAGE, which refers to the size of the main tumor and the presence or absence of lymph node or distant (to other areas in the body) metastases. It is possible to have a "low grade / well-differentiated" tumor that is diagnosed at an advanced stage, and it is also possible to have a "high grade / poorly differentiated" tumor that is early-stage.

It used to be thought that stage of disease (size of tumor, presence or absence of lymph node metastases) was the most important prognostic indicator. We are learning more about how the biologic behavior (grade is just one component of the behavior of a tumor) may be more important in many cases than the stage at diagnosis. The following information is a good summary of tumor grade, taken from http://www.cancerfacts.com/DefaultSecure.asp "Tumor grade (G) is an evaluation of how abnormal a cancer cell is compared to the normal cells from which it arises. This evaluation is called the "histologic tumor grade" and is done by the pathologist when examining the biopsy specimen. Histology is the study of the microscopic structure of the cells, which helps to predict how the cancer will behave. An objective score is given to each of three structural features of the tumor. A score of 1 (the most favorable) to 3 (the least favorable) is given for each feature.

The total score determines the tumor grade. This system describes the cell in terms of how well the cancer cell resembles the normal cell from which it arises. If the cancer cell looks very much like a normal breast cell, then it is called "well-differentiated". If the cancer cell poorly resembles a normal breast cell or not at all, then it is called "poorly differentiated or undifferentiated".

GX: grade cannot be assessed, undetermined grade
G1: well differentiated (low grade) This is the most favorable grade and reflects a total score of 3-5
G2: moderately differentiated (intermediate grade) This reflects a score of 6-7
G3: poorly differentiated (high grade) This is the least favorable grade, with a score of 8-9

Different systems are used to categorize the histologic (referring to tissue) tumor grade. The NCCN currently recommends using The Nottingham combined system for grading tumors. Another classification system is the Bloom-Richardson Score. The systems are similar: the higher the score, the less favorable the tumor.

The tumor grade can influence treatment decisions, especially if additional treatment such as chemotherapy or hormone therapy is needed after surgery."

It is important to note the difference between tumor GRADE, which as described above comments on the individual cancer cell, and tumor STAGE, which refers to the size of the main tumor and the presence or absence of lymph node or distant (to other areas in the body) metastases. It is possible to have a "low grade / well-differentiated" tumor that is diagnosed at an advanced stage, and it is also possible to have a "high grade / poorly differentiated" tumor that is early-stage.

It used to be thought that stage of disease (size of tumor, presence or absence of lymph node metastases) was the most important prognostic indicator. We are learning more about how the biologic behavior (grade is just one component of the behavior of a tumor) may be more important in many cases than the stage at diagnosis.

The HALO test is meant to be used as a risk assessment tool, not a cancer detection test - it primarily meant for women under the age of about 40 (in whom routine mammography is not performed). The idea is that if there are abnormal cells lining the milk ducts, they may be detected in the fluid obtained from the test. If there are abnormal cells, that generally signifies an increased risk of developing cancer, and additional testing (perhaps MRI) may be indicated.

When properly performed, as many as 50% of women will not produce fluid with the HALO test, and in young women, this is considered a "negative" result (no abnormality). However with the normal aging process, there can be atrophy of the milk ducts, so that in women over the age of 40-50, no fluid might be due to changes related to age, and not necessarily a negative result. In addition, the HALO test will probably not pick up abnormal cells even if a cancer is present if the tumor is in the outer aspects of the breast. Lobular cancer (as it is not growing initially in the milk ducts) also will not likely be picked up with the HALO test.

The HALO test is not for everyone and again it is important to stress that this test is not meant to be a screening test for breast cancer, and is not a substitute for clinical and self-examination as well as routine imaging such as mammogram (and ultrasound / MRI if indicated). However when used appropriately it can be helpful to provide some counseling to young women regarding their risk. The HALO test is meant to be used as a risk assessment tool, not a cancer detection test - it primarily meant for women under the age of about 40 (in whom routine mammography is not performed). The idea is that if there are abnormal cells lining the milk ducts, they may be detected in the fluid obtained from the test. If there are abnormal cells, that generally signifies an increased risk of developing cancer, and additional testing (perhaps MRI) may be indicated.

When properly performed, as many as 50% of women will not produce fluid with the HALO test, and in young women, this is considered a "negative" result (no abnormality). However with the normal aging process, there can be atrophy of the milk ducts, so that in women over the age of 40-50, no fluid might be due to changes related to age, and not necessarily a negative result. In addition, the HALO test will probably not pick up abnormal cells even if a cancer is present if the tumor is in the outer aspects of the breast. Lobular cancer (as it is not growing initially in the milk ducts) also will not likely be picked up with the HALO test.

The HALO test is not for everyone and again it is important to stress that this test is not meant to be a screening test for breast cancer, and is not a substitute for clinical and self-examination as well as routine imaging such as mammogram (and ultrasound / MRI if indicated). However when used appropriately it can be helpful to provide some counseling to young women regarding their risk.

Surgeons, and especially breast surgeons, are trained not only in the evaluation and management of patients with malignancy, but in the evaluation and management of patients with benign breast disease as well. Except in the situation where the surgeon has limited their practice to patients with breast cancer, many breast surgeons have a large number of patients in their practice with benign breast conditions (cysts, benign tumors, breast pain, abnormal but not necessarily suspicious mammogram, high-risk screening, etc) - many of my patients will never need an operation. My role is to perform the workup, often the ultrasound and/or needle biopsy myself, and then determine if cancer is present or not. Once cancer is diagnosed, the breast surgeon will work with the medical oncologist and radiation oncologist as a team to decide in a multidisciplinary fashion what the best treatment is. My surgeon answered this question when I asked why I needed to keep seeing him after I finished my active treatment for inflammatory breast cancer. He said, "oncologists treat cancer but are not trained to diagnose cancer." When I questioned my oncologist, he basically gave the same answer, saying "I treat cancer once it's been found." In the case of breast cancer, a breast specialist/breast surgeon is typically the person who will do the necessary steps to obtain a diagnosis, then work in tandem with the oncologist to determine how to proceed with treatment. This is my understanding and should not be viewed as medical advice.

Unfortunately during the day, I don't have much down time. However when things get hectic, if I can, I make a cup of tea! While it's possible to gulp down a soda or inhale a snack, it is almost impossible not to slow down when you're sipping a good cup of green tea. If I have 10-15 minutes, sipping the tea makes me to breathe a little slower, find my center, and refocus. Plus, no calories! Many times during the day I can get stressed out; teenagers, work and health issues are usually the cause. And many times there is just no time to grab an hour here or there to meditate uninterrupted! So I compiled a CD of some really "feel good" insirational songs I especially love to sing along with and play it in the car whenever I am feeling stressed or down. Works for me! :)

Myriad Genetics (http://www.myriad.com/) has had BRCA 1 and 2 testing available since 1996. Currently there are over 2000 variations in BRCA 1 and 2 genes that have been shown to be "deleterious" mutations, in that they are responsible for an increased risk in breast and ovarian cancer. New deleterious mutations are being discovered and confirmed with some regularity.

At this point, approximately 5% of mutations identified are labeled "mutations of undetermined significance" - this means that there is a gene abnormality, but there is not enough data to know if the mutation is a harmful one or not - realize that many gene mutations do not confer an increased risk. According to one of the researchers at Myriad, when they first started testing in 1996, "15 to 40% of the people getting tested had a variant of uncertain significance. That is now under 5%, because we have made enormous progress in our ability to study variants and figure out if they cause an increased risk for cancer. But there are still a lot of variants for which we need more information". Myriad Genetics (http://www.myriad.com/) has had BRCA 1 and 2 testing available since 1996. Currently there are over 2000 variations in BRCA 1 and 2 genes that have been shown to be "deleterious" mutations, in that they are responsible for an increased risk in breast and ovarian cancer. New deleterious mutations are being discovered and confirmed with some regularity.

At this point, approximately 5% of mutations identified are labeled "mutations of undetermined significance" - this means that there is a gene abnormality, but there is not enough data to know if the mutation is a harmful one or not - realize that many gene mutations do not confer an increased risk. According to one of the researchers at Myriad, when they first started testing in 1996, "15 to 40% of the people getting tested had a variant of uncertain significance. That is now under 5%, because we have made enormous progress in our ability to study variants and figure out if they cause an increased risk for cancer. But there are still a lot of variants for which we need more information".

A recurrence of the original primary tumor or a new tumor can be devastating psychologically - while many women understand that cancer can come back, no one expects it, just like most don't expect the original diagnosis. Take some deep breaths, and as noted above, face it head-on. Try not to let your emotions and fears get the best of you, and realize that science and treatment advances may mean better and more effective treatment options than were available to you previously. A recurrence of the original primary tumor or a new tumor can be devastating psychologically - while many women understand that cancer can come back, no one expects it, just like most don't expect the original diagnosis. Take some deep breaths, and as noted above, face it head-on. Try not to let your emotions and fears get the best of you, and realize that science and treatment advances may mean better and more effective treatment options than were available to you previously.

It is so important to have realistic expectations and pace yourself!! Do not get frustrated - just do what you can. It's ok to push yourself a little, but remember that your body and mind have been through so much with surgery, chemotherapy, radiation, and the emotional exhaustion. Doing something is beneficial, but don't feel that you have to run marathons to gain the benefits from exercise. And I agree that resting, sleep and proper nutrition are so important - you cannot heal without attention to them - think of them as your new friends! The easiest way to get back into exercise is not to stop during treatment. I remember the doctor told me to walk and begin exercise the day after my bilat MX. It was freezing out and my coat would not fit over my drains, so I walked the stairs in my building. When finished, I was exhausted and slept for 16 hours. From then on I made sure I walked every day until the doctor said I could run. I also went to physical therapy, which was a big help. She gave me safe exercises to do to regain muscle function and insisted I ride the exercise bike and did some stretching and massage to help with the healing. I really believe the exercise helped me heal quickly, both mentally as well as physically. If you have had a MX, be sure to buy a zip front snug sports bra as this will make exercise much more comfortable than if wearing the surgical bra.

I just posted a guest blog by David Haas on my site, some good info on this topic: http://elynjacobs.blogspot.com/2011/08/health-fitness-helps-cancer-patients.html" target=_blank>http://elynjacobs.blogspot.com/2011/08/health-fitness-helps-cancer-patients.html

Don't forget your protein! An excellent low-fat, non-soy source of protein: quinoa! This "grain" (it's actually a seed) cooks in about 15 minutes, and is a a complete protein. It has a slightly nutty taste and can be used in a variety of ways - a quick google search will give you a lot of options. I make a big batch in vegetable or homemade chicken broth, and then freeze in individual serving containers, so I've always got an easy quick way to add protein to any meal. Smoothies

So about a month ago, my roommate was making smoothies for a while in our blender. They’d look so yummy, and when he gulped them down, he made a big MMMM!!! Sound. I was inspired. I bought a bunch of berries and bananas, threw them into my blender with some milk and my weight gainer supplement shake (I’m a small guy) press pulse, and Voila! Delicious! I could feel a cold splash of goodness hit my stomach as it went down.

Now I can’t stop. I make about 2 or 3 smoothies a day. I add my supplement shake, and I’m full and nourished all through the day! Now, I’ve always been a huge meet eater. I always got the fattest, saltiest, sugar filled BBQ Sauce, and whatever meat I could find. Since I started on smoothies, I’ve been noticing that I’ve desired less and less, and about a week ago as I was lifting a spoon of Hamburger Helper, I got this sick sort of feeling and said to myself, “Man… I don’t really want this… at all. Uh oh… Am I becoming a non-meat eater?”

So I really don’t eat meat at all anymore, sometimes when I’m at a restaurant, but usually I’ll order fish.

So try to start on smoothies, and see if you get addicted to the super healthy anti-cancer power breakfast – it may dilute your desire for other unhealthy things, such as anything with added sugar. Cancer cells live off of sugar! Not only am I feeling great, I feel it’s just one of many things I do to stomp my dead cancer on the face.

Don't underestimate the power of a good nurse navigator! Often times the options for help and support are overwhelming, and as Debbie mentioned, the patient may not know what she needs. A good navigator will take the time to get to know you, your concerns, fears and issues, and will recommend programs that can be helpful. Do not be afraid to seek these people out and ask for their help! People transitioning from cancer patient to survivor need programs that speak to their physical, emotional, spiritual and social needs. I took advantage of counseling, rehabilatative exercise, support groups and stress reduction classes. Interestingly, survivors don't always know what programs they need because the transition is so overwhelming. That's why access to a patient navigator is crucial to their success. I know from my own experience how important my navigator was to my healing.

Whether you use the term survivor, warrior, or some other descriptor, your cancer experience is no less "real" than someone diagnosed in a more advanced stage. When you hear the word cancer, and they're talking about you, the fears, concerns, and emotional ups and downs are no different regardless of the stage at diagnosis. It is a confusing diagnosis. Some would argue it's not "real" cancer since it hasn't spread (yet)--my running joke with my oncologist was "It's close enough! Someone sign me up for the fake mastectomy!" At first I didn't think I had earned the right to call myself a survivor since I wasn't in a fight for my life. Then I realized my experience counts for something, and as I mentioned elsewhere, no one with advanced cancer has ever made me feel like I had a lesser version. Talking to others who have been through it helped a lot too. I talked to a friend who had had early-stage cancer (not stage 0) and she said she felt the same way and she thinks it's normal for it to take awhile to consider ourselves survivors. Just hearing that helped a lot.

PreparedPatient your answer was excellent advice, and I think the article is a very helpful resource. I'd add that as physicians, we're used to hearing personal, intimate and embarrassing information - if you can't ask your doctor, who can you ask? We're here to give support and advice, not to judge. It's important to get answers to your questions. And I agree - if you don't feel comfortable opening up to your doctor, it's probably time to find a new one! It can be hard to talk to doctors about our symptoms if they’re embarrassing or deeply personal, if they are about sexual activities or concerns, or if you fear you may be judged or criticized. But doctors deal with intimate personal information all the time. Whatever your problem is, the doctor has probably seen or heard it before. If you really can’t talk to your doctor about your problem, it’s probably time to think about finding a new doctor who you can trust.

For more advice about talking to your providers about symptoms, see our full-length feature article: http://www.cfah.org/hbns/preparedpatient/Vol3/Prepared-Patient-Vol3-Issue8.cfm

This is a difficult issue - if your breast cancer was estrogen-receptor negative, then removal of the ovaries will not necessarily reduce the risk of recurrence, but might reduce the risk of a new breast cancer developing over time. If your breast cancer was estrogen-receptor positive, then the goal is to reduce the amount of estrogen that your breast tissue is exposed to in order to help reduce the risk of recurrence or new disease developing. Years ago, removal of the ovaries was a standard part of breast cancer treatment. Most often now it is performed in women that carry the BRCA 1 and 2 mutations, as they have a significantly elevated risk of developing ovarian cancer.

As with any prophylactic surgery, removal of the ovaries is a difficult decision, especially in a premenopausal woman. Menopausal symptoms can sometimes be severe, and bone loss is a real concern as well. And once the ovaries are removed, they can't be put back...you may want to ask your doctor about other options, such as a trial of lupron (which will induce a "chemical menopause" - but at least it's reversible if you don't do well on it). This is a difficult issue - if your breast cancer was estrogen-receptor negative, then removal of the ovaries will not necessarily reduce the risk of recurrence, but might reduce the risk of a new breast cancer developing over time. If your breast cancer was estrogen-receptor positive, then the goal is to reduce the amount of estrogen that your breast tissue is exposed to in order to help reduce the risk of recurrence or new disease developing. Years ago, removal of the ovaries was a standard part of breast cancer treatment. Most often now it is performed in women that carry the BRCA 1 and 2 mutations, as they have a significantly elevated risk of developing ovarian cancer.

As with any prophylactic surgery, removal of the ovaries is a difficult decision, especially in a premenopausal woman. Menopausal symptoms can sometimes be severe, and bone loss is a real concern as well. And once the ovaries are removed, they can't be put back...you may want to ask your doctor about other options, such as a trial of lupron (which will induce a "chemical menopause" - but at least it's reversible if you don't do well on it).

Approaching these changes with the right attitude is so important! As Jan mentioned, it is not as difficult as you would expect when you know you are doing what is right for your body and spirit. And I'll reinforce Tami's comment about reducing stress - stress is a part of life, but there are a lot of stressful situations that crop up in our daily lives that are "optional". Learn to pick your battles, control your environment and your response to it as much as possible, and find ways to reflect the stress off of you or somehow let it go. Meditation, yoga, visualization and guided imagery can be very powerful tools. Thanks for your question! I have done a number of things, the most important of which, is quitting a stressful job and doing what I love. I eat a whole-foods, organic diet, greatly reducing sugar, white flour, dairy and red meat, and eliminating soda and alcohol. I drink two cups daily of Dr. Lee's green tea (five times the cancer-fighting properties of normal green tea) I exercise daily and do a lot of prayer and visualization. I also take a number of supplements and consult with integrative practitioners, most recently the Block Center in Chicago.

Has it been difficult? Yes, sometimes, but I've gotten used to it, and it makes me feel empowered that I'm doing something to impact my health. Hope that answers your question!

Unfortunately lymphedema does remain a problem, and as mentioned above, it can develop even after the removal of only one sentinel lymph node. However what has improved is awareness of the problem as well as the understanding that early detection and prompt evaluation and treatment by a certified lymphedema therapist can help keep the swelling under good control. Historically we have used tape measures or other relatively crude methods to assess swelling. A newer test (the L-Dex; http://www.impedimed.com/home.htm ), uses bioimpedence spectroscopy (differences in the rate of conduction of an electrical current) to detect differences in fluid content in a patient's arm before there is actually evidence of swelling, and studies are demonstrating that this very early detection leads to improved outcomes. Yes, it is; though the risk for lymphedema is markedly reduced with sentinel node biopsy compared to full axillary dissection.

In addition to degree of dissection, other risk factors for lymphedema have been identified: obesity, advanced age and extensive axillary involvement with tumor.

All are great answers and good advice. I would stress that just because a lump might feel soft and movable, don't assume that it is not something more suspicious. Always get a new finding evaluated by your physician. If you are not comfortable with the response, get another opinion, preferably from a specialist. Young women especially should never be dismissed or told that "you're too young" for breast cancer. I also agree fully with LaurieA - bring a friend or family member to your appointment! Make an appointment with your gynecologist, who will give you a breast exam. Hopefully, you'll find it is nothing. Otherwise, based on your symptoms, you might be asked to see a radiologist for a mammogram and/or sonogram. If there is still suspicion, but no certainty, you may also be asked to have an MRI.

It is important to act quickly. Don't put your head in the sand. If it is breast cancer, you want it to be detected as soon as possible. Early detection means more choices and more control. And, it gives you the best chance for survival.

I do believe that hearing about the successful treatment of other patients helps - we all need hope! And when you hear of the successful treatment of another patient, even if your condition is different, it gives you that hope, which can give you the strength to keep fighting and to keep going through treatment. You cannot underestimate the power of hope and positive thinking in any situation in life, but especially when dealing with the potentially life-threatening disease of cancer. I do believe that hearing about the successful treatment of other patients helps - we all need hope! And when you hear of the successful treatment of another patient, even if your condition is different, it gives you that hope, which can give you the strength to keep fighting and to keep going through treatment. You cannot underestimate the power of hope and positive thinking in any situation in life, but especially when dealing with the potentially life-threatening disease of cancer.

In general, a relatively low-fat, varied diet is best for most of us, whether we have had cancer, other medical condition, or are just trying to optimize our health. Personally I've never been a fan of "no fat", "no / low carb" or "high protein" diets. By eating a variety of fruits and vegetables, as well as lean protein sources and whole-grains and healthy fats, you can get most of the vitamins, minerals, fiber, and other nutrients that you need. However an occasional splurge is also fine - life is too short to go without chocolate! Just make it good quality, dark if possible.

Specifically for women that have been treated for breast cancer, soy is very controversial due to the fact that it can have estrogen-like properties. I recommend avoiding soy in supplement or highly processed form, but moderate dietary amounts of good-quality, minimally processed soy foods are probably save. However this is an area of ongoing research and recommendations may change over time. In general, a relatively low-fat, varied diet is best for most of us, whether we have had cancer, other medical condition, or are just trying to optimize our health. Personally I've never been a fan of "no fat", "no / low carb" or "high protein" diets. By eating a variety of fruits and vegetables, as well as lean protein sources and whole-grains and healthy fats, you can get most of the vitamins, minerals, fiber, and other nutrients that you need. However an occasional splurge is also fine - life is too short to go without chocolate! Just make it good quality, dark if possible.

Specifically for women that have been treated for breast cancer, soy is very controversial due to the fact that it can have estrogen-like properties. I recommend avoiding soy in supplement or highly processed form, but moderate dietary amounts of good-quality, minimally processed soy foods are probably save. However this is an area of ongoing research and recommendations may change over time.

This is always a difficult one as there are so many variables that go into the cosmetic outcome depending on issues having to do with the patient, tumor, and surgeon. I recommend that most patients obtain more than one opinion, and ask to see pictures, preferably of patients with a similar body type to yours. This is always a difficult one as there are so many variables that go into the cosmetic outcome depending on issues having to do with the patient, tumor, and surgeon. I recommend that most patients obtain more than one opinion, and ask to see pictures, preferably of patients with a similar body type to yours.

I do let patients know that while the sentinel node procedure is done through a very small incision (usually 1/2 inch or smaller), it can be the most painful part of the surgery. The lymph nodes are tucked deep in the underarm, below the pectoralis (chest wall) muscle - in order to get to them (especially through a small incision), some retraction on the muscle during surgery is needed.

I always give patients a booklet on exercises prior to surgery (there's a good little one put out by the American Cancer Society) and recommend that they start doing the exercises before surgery - it's good to get your body used to the stretches and other exercises before you're having any discomfort. And I encourage an early return to activity - initially the stretching exercises, followed by more regular exercise. Some patients do require physical therapy and we try to identify this sooner rather than later. I do let patients know that while the sentinel node procedure is done through a very small incision (usually 1/2 inch or smaller), it can be the most painful part of the surgery. The lymph nodes are tucked deep in the underarm, below the pectoralis (chest wall) muscle - in order to get to them (especially through a small incision), some retraction on the muscle during surgery is needed.

I always give patients a booklet on exercises prior to surgery (there's a good little one put out by the American Cancer Society) and recommend that they start doing the exercises before surgery - it's good to get your body used to the stretches and other exercises before you're having any discomfort. And I encourage an early return to activity - initially the stretching exercises, followed by more regular exercise. Some patients do require physical therapy and we try to identify this sooner rather than later.

That's a great question. We used to focus on the "magic" 5-year or 10-year mark, and I think we did women a disservice. The risk of recurrence decreases the longer out you are from treatment, but there is always a risk of a new cancer developing, breast or elsewhere. Follow up recommendations will vary depending on the type of cancer, age of the patient, and other factors.

For breast cancer in general for long-term survivors, I recommend an annual clinical exam with your physician, as well as annual imaging (mammogram and possibly MRI depending on breast density and age). In addition, women who have been treated for breast cancer have a slightly higher risk of both colon and ovarian cancer, even if they do not test positive for a BRCA gene mutation, so regular gynecologic checkups and colonoscopy are also recommended.

In addition, I do recommend that women (and men) who have been treated for cancer take general good care of themselves! Maintaining a healthy weight, following a good balanced diet with moderation in alcohol intake, and obtaining regular exercise will not only help reduce the risk of other cancers developing, but these lifestyle factors will help reduce the risk of heart disease, which is actually more lethal for women than breast cancer. Also don't underestimate the role of chronic stress as a contributing factor to all disease states, so I do recommend that most patients try to incorporate some stress-reduction techniques into their daily routine. These last recommendations are not very high-tech, but can certainly be quite effective! That's a great question. We used to focus on the "magic" 5-year or 10-year mark, and I think we did women a disservice. The risk of recurrence decreases the longer out you are from treatment, but there is always a risk of a new cancer developing, breast or elsewhere. Follow up recommendations will vary depending on the type of cancer, age of the patient, and other factors.

For breast cancer in general for long-term survivors, I recommend an annual clinical exam with your physician, as well as annual imaging (mammogram and possibly MRI depending on breast density and age). In addition, women who have been treated for breast cancer have a slightly higher risk of both colon and ovarian cancer, even if they do not test positive for a BRCA gene mutation, so regular gynecologic checkups and colonoscopy are also recommended.

In addition, I do recommend that women (and men) who have been treated for cancer take general good care of themselves! Maintaining a healthy weight, following a good balanced diet with moderation in alcohol intake, and obtaining regular exercise will not only help reduce the risk of other cancers developing, but these lifestyle factors will help reduce the risk of heart disease, which is actually more lethal for women than breast cancer. Also don't underestimate the role of chronic stress as a contributing factor to all disease states, so I do recommend that most patients try to incorporate some stress-reduction techniques into their daily routine. These last recommendations are not very high-tech, but can certainly be quite effective!

There are many things to consider prior to surgery for breast cancer, but I think that one of the most important is to provide emotional support for the patient and her family during this very difficult time. While we often have a good idea of what we are dealing with based on the mammogram, ultrasound, MRI and other tests, there is always some uncertainty until the final pathology results are available. Trying to prepare a woman and her family for the possible scenarios that we may encounter based on the surgical findings and pathology results while also trying to be reassuring that she will be "ok" is sometimes a tough balancing act.

I do feel that having information is very helpful, and reviewing the step-by-step process of what will happen in the hospital on the day of the surgery seems to be very helpful. I also review what to expect after surgery as well, in terms of discomfort, resuming normal activity, and returning to work. Sometimes having a patient speak to other women who have undergone a similar procedure can provide some support.

While most women do go into the surgery fairly anxious, at least if they understand what will happen before, during, and after, some of the mystery is taken out of the whole process. There are many things to consider prior to surgery for breast cancer, but I think that one of the most important is to provide emotional support for the patient and her family during this very difficult time. While we often have a good idea of what we are dealing with based on the mammogram, ultrasound, MRI and other tests, there is always some uncertainty until the final pathology results are available. Trying to prepare a woman and her family for the possible scenarios that we may encounter based on the surgical findings and pathology results while also trying to be reassuring that she will be "ok" is sometimes a tough balancing act.

I do feel that having information is very helpful, and reviewing the step-by-step process of what will happen in the hospital on the day of the surgery seems to be very helpful. I also review what to expect after surgery as well, in terms of discomfort, resuming normal activity, and returning to work. Sometimes having a patient speak to other women who have undergone a similar procedure can provide some support.

While most women do go into the surgery fairly anxious, at least if they understand what will happen before, during, and after, some of the mystery is taken out of the whole process.

This will completely depend on the type of tumor. Some of the more aggressive cancers actually respond best to chemotherapy as neoadjuvant treatment, while some of the less aggressive tumors may respond better to anti-estrogen therapy (tamoxifen or an aromatase inhibitor). Tumors that over-express Her2/neu will often respond best to a combination of chemotherapy and herceptin. Newer molecular profiling tests that are done on the breast cancer (MammaPrint and Oncotype Dx) can give us some very helpful information regarding the aggressiveness of a cancer as well as the potential for response to different therapies. Each case is really individualized, and we are now more than ever better able to tailor a particular regimen to a patient's individual cancer for the best results. This will completely depend on the type of tumor. Some of the more aggressive cancers actually respond best to chemotherapy as neoadjuvant treatment, while some of the less aggressive tumors may respond better to anti-estrogen therapy (tamoxifen or an aromatase inhibitor). Tumors that over-express Her2/neu will often respond best to a combination of chemotherapy and herceptin. Newer molecular profiling tests that are done on the breast cancer (MammaPrint and Oncotype Dx) can give us some very helpful information regarding the aggressiveness of a cancer as well as the potential for response to different therapies. Each case is really individualized, and we are now more than ever better able to tailor a particular regimen to a patient's individual cancer for the best results.

Neoadjuvant therapy refers to chemotherapy or anti-estrogen therapy administered before surgery - usually in an attempt to decrease the size of the tumor. One situation where neoadjuvant therapy is helpful is if the tumor is too large to remove with lumpectomy and still leave an acceptable cosmetic result - neoadjuvant therapy can shrink the tumor to allow for a more cosmetic lumpectomy. Another situation when neoadjuvant therapy is used is if the tumor is already invading into the skin or muscle - it can be very difficult to perform surgery in these situations, so often chemotherapy will be used prior to surgery.

It is important to realize that in cases where neoadjuvant therapy is given, tumors do not always shrink concentrically - in other words, they sometimes shrink in some areas but leave little pockets of cancer cells behind. For that reason if I have a patient undergoing neoadjuvant therapy, I will often obtain an MRI prior to surgery to make as sure as possible that we are not dealing with a situation where there are multiple pockets of cancer cells remaining. Neoadjuvant therapy refers to chemotherapy or anti-estrogen therapy administered before surgery - usually in an attempt to decrease the size of the tumor. One situation where neoadjuvant therapy is helpful is if the tumor is too large to remove with lumpectomy and still leave an acceptable cosmetic result - neoadjuvant therapy can shrink the tumor to allow for a more cosmetic lumpectomy. Another situation when neoadjuvant therapy is used is if the tumor is already invading into the skin or muscle - it can be very difficult to perform surgery in these situations, so often chemotherapy will be used prior to surgery.

It is important to realize that in cases where neoadjuvant therapy is given, tumors do not always shrink concentrically - in other words, they sometimes shrink in some areas but leave little pockets of cancer cells behind. For that reason if I have a patient undergoing neoadjuvant therapy, I will often obtain an MRI prior to surgery to make as sure as possible that we are not dealing with a situation where there are multiple pockets of cancer cells remaining.

There are several different types of breast surgery - the 2 basic categories are lumpectomy and mastectomy. Lumpectomy (also referred to as partial mastectomy) generally refers to removing the breast cancer with a rim of normal surrounding tissue, the margin. Mastectomy refers to removal of the entire breast, and often is accompanied by reconstructive surgery. With both lumpectomy and mastectomy, usually a sentinel lymph node biopsy is performed - a few underarm lymph nodes are removed to confirm if the cancer has spread or not.

For benign breast tumors (not cancer), generally an excisional biopsy is performed - this simply means removal of the breast lump. There are several different types of breast surgery - the 2 basic categories are lumpectomy and mastectomy. Lumpectomy (also referred to as partial mastectomy) generally refers to removing the breast cancer with a rim of normal surrounding tissue, the margin. Mastectomy refers to removal of the entire breast, and often is accompanied by reconstructive surgery. With both lumpectomy and mastectomy, usually a sentinel lymph node biopsy is performed - a few underarm lymph nodes are removed to confirm if the cancer has spread or not.

For benign breast tumors (not cancer), generally an excisional biopsy is performed - this simply means removal of the breast lump.

Congratulations on being 3 years out from your breast cancer - sounds like you went through quite an ordeal. The most important thing to remember is that while you have no visible damage from the radiation therapy, radiation treatment does alter the blood flow to the skin and breast tissue and can affect the healing process from even minor procedures. However most times there are no significant issues. It sounds like you have already done some research on your physician and the fact that you feel comfortable with her is important. I would just confirm that she has experience in working with patients who have undergone radiation therapy for a prior breast cancer - it is not the same as a standard cosmetic reduction. Good luck with your upcoming procedure! Congratulations on being 3 years out from your breast cancer - sounds like you went through quite an ordeal. The most important thing to remember is that while you have no visible damage from the radiation therapy, radiation treatment does alter the blood flow to the skin and breast tissue and can affect the healing process from even minor procedures. However most times there are no significant issues. It sounds like you have already done some research on your physician and the fact that you feel comfortable with her is important. I would just confirm that she has experience in working with patients who have undergone radiation therapy for a prior breast cancer - it is not the same as a standard cosmetic reduction. Good luck with your upcoming procedure!

There are so many, but here are a few that I've found to be helpful -
National Center for Complementary and Alternative Medicine:
http://www.nccam.nih.gov/

Memorial Sloan-Kettering Cancer Center "About Herbs":
http://www.mskcc.org/mskcc/html/11570.cfm

MD Anderson Complementary and Integrative Medicine Education Resources:
http://www.mdanderson.org/education-and-research/resources-for-professionals/clinical-tools-and-resources/cimer/index.html

University of Arizona Center for Integrative Medicine:
http://integrativemedicine.arizona.edu/

American Cancer Society - Herbs, Vitamins, and Minerals:
http://www.cancer.org/Treatment/TreatmentsandSideEffects/ComplementaryandAlternativeMedicine/HerbsVitaminsandMinerals/index
EmbodiWorks at http://www.embodiworks.org/ provides reliable integrative cancer care resources. Addressing whole person health and healing in five areas, topics include body, mind, and spirit, including social and environmental health. The Resources section helps cancer patients and caregivers navigate their cancer journey as well. Various ways to create an integrative cancer care program, questions for evaluating cancer treatments and providers, help in evaluating cancer research and treatments, integrative providers and clinics, retreats, books, financial assistance, and other trustworthy resources empowers people with, through, and beyond cancer. Articles also inform cancer care providers with some practitioners serving as authors. Scientific references are incorporated throughout their site. For EmbodiWorks educational resources to help reduce cancer risk and improve cancer-related survival, quality of life, and whole person health care, visit www.embodiworks.org.

Having atypical ductal hyperplasia (ADH - typically found on a needle biopsy performed for concerning calcifications on a mammogram) does indicate an increased risk for the future development of breast cancer. If ADH is found on a needle biopsy, most would recommend surgery to remove that area as there is a small possibility that a cancer might be present, just missed on the needle biopsy. If no cancer is present, options include close surveillance (which might include MRI exams in addition to mammograms) and consideration for the use of tamoxifen or raloxifene as preventative agents. It is important to understand that the increased risk for the future development of breast cancer can be in either breast, not just the one that had the ADH. Having atypical ductal hyperplasia (ADH - typically found on a needle biopsy performed for concerning calcifications on a mammogram) does indicate an increased risk for the future development of breast cancer. If ADH is found on a needle biopsy, most would recommend surgery to remove that area as there is a small possibility that a cancer might be present, just missed on the needle biopsy. If no cancer is present, options include close surveillance (which might include MRI exams in addition to mammograms) and consideration for the use of tamoxifen or raloxifene as preventative agents. It is important to understand that the increased risk for the future development of breast cancer can be in either breast, not just the one that had the ADH.

I'd love to jump in but it was such a complete answer, I don't have much to add! I will however reinforce that despite all of our advances, there is still so much that we don't know and there are still a lot of unanswered questions. Environmental influences probably play a greater role than we currently appreciate, and we are becoming more aware of the influence of lifestyle factors such as diet, activity level / weight, and alcohol intake. The balancing act continues. I was so lucky...I had a team of doctors who were very forthcoming in providing information I would need, so it's actually hard to say. I was also pre-menopausal so the options for hormone therapy were clear - tamoxifen was and remains the gold standard. I can tell you, however, that when I was diagnosed there wasn't talk about luminal A vs. luminal B vs. other cancers. I'm not sure when those categories came into view, but at the time Herceptin was new and Arimidex was just emerging from clinical trial (I THINK I have my timing right - please correct me if I'm wrong!) I'm obviously not a doctor, and I'd love to have one jump in here...

However, even today, the issues that remain for me revolve around what I can do to keep myself healthy. The challenge is that there is STILL so much we don't know about hormone status and also importantly, what in the environment (using that term loosely) impacts hormone levels. Since my treatments, hormone replacement therapy (HRT) is OUT. I've yet to hear a final word on soy. Obesity and wine both produce estrogen. On the other hand, hormone-free animal products, from meat to milk, are widely available.

And then, we can rest assured that another threat is around the corner. As an example of what it lurking, I offer the pesticide atrazine. I was at a program run by the California Breast Cancer Research Program, with a primary focus on the role of the environment on breast cancer. It was there that I learned about atrazine, used particularly on corn (which is, of course, ubiquitous in today's ready-to-eat world of processed foods). According to studies, atrazine has not only led to the development of ovaries in male frogs, but those frogs have actually been able to reproduce (http://www.livescience.com/10957-pesticide-turns-male-frogs-females.html).

I'm not sure I answered your question directly and sadly, there remains so much we don't know. For what it is worth, I work hard at finding that balance between remaining aware and vigilant, with embracing a full, rich life.

While it is not common, some patients do have persistent numbness, itching, or hypersensitivity, even years after surgery and radiation therapy. Usually there is not anything specific causing the sensation, but I would certainly recommend bringing this to the attention of your physician and make sure that you keep up with the recommended imaging studies and exams after surgery. While it is not common, some patients do have persistent numbness, itching, or hypersensitivity, even years after surgery and radiation therapy. Usually there is not anything specific causing the sensation, but I would certainly recommend bringing this to the attention of your physician and make sure that you keep up with the recommended imaging studies and exams after surgery.

Navigators are priceless! I am fortunate at my hospital to work with one and she is invaluable to both the patients and physicians. She is an active participant in our multidisciplinary conferences, tumor boards, and cancer committee meetings, and often is able to provide the docs with additional insight into the patient's physical, mental/emotional, and social situations - information that we might not otherwise have - and information that allows us to take better care of our patients as we gain a better understanding about what they are going through. The primary responsibilities for the navigator depends on the setting that he/she is working in. It is a relative new position and was started to address disparities in breast cancer. Dr. Harold Freeman from the Ralph Lauren Breast Center For Cancer Care and Prevention (in Harlem) is one (if not the first) person to identify the need for this position. He has founded an online patient navigation training program and for information you can check out their website....info@hpfreemanpni.org. In 2009 they had an Institute to train navigators and I was lucky enough to attend,
it was an amazing learning experience and Dr. Freeman is very dedicated to the cause. If you google Dr. Freeman you can read about the history about navigation and the studies that he based his research on.

I know that patient navigation has caught on beyond breast cancer. At Columbia Presbyterian there are navigators working with colon cancer patients and also in the ER. I know of many hospitals in the city that have navigators and many of the position are grant based positions. There can be different types of navigators...I am a lay navigator (a trained survivor) and there are also nurse navigators too, they are often called case managers.

Please let me know if you have any questions about the position...I have found it to be an amazing career and just what I needed after dealing with my own breast cancer journey.

DCIS is often more difficult to deal with surgically than invasive cancer, although the prognosis is much better. It generally does not form a lump or mass, and sometimes there are not even any calcifications, so it is often difficult to get an appreciation of just how much disease is present. MRI may not always even be helpful in determining the extent of disease. I often tell my patients that DCIS may not be a threat to your life but it can be a threat to the breast.

However if you have a small focus of DCIS that can be removed with lumpectomy (and a good cosmetic result), it is very reasonable to consider lumpectomy with radiation therapy. When I was initially diagnosed with DCIS, I was told I would probably need a lumpectomy and radiation. Later, the breast surgeon recommended a mastectomy. I had a hard time understanding why I needed such a radical procedure. My doctor explained that the micro-calcification fields were extensive - thus a lumpectomy would leave me deformed. Also, the radiologist couldn't say for sure that a lumpectomy would successfully remove all of the micro-calcifications. When I realized that the mastectomy was necessary both for my health and as a means to a more successful reconstruction, I made the decision for mastectomy.

Generally if there is retraction of the nipple, that is because there is cancer behind the nipple or areola, and it "draws" the nipple inwards. Depending on the exam and findings of the imaging studies (especially MRI), preserving the nipple and areola might not be possible. If the nipple and areola do need to be removed, sometimes a "central lumpectomy" can be performed - again this depends on the location and size of the tumor as well as the size and appearance of the overall breast. If a central lumpectomy is performed, radiation therapy will be needed, as with any lumpectomy. Radiation is generally not needed after mastectomy, unless there is a very large tumor, if there is invasion of tumor into the skin, or if multiple lymph nodes are involved by tumor.

I would make sure you get a good idea of the cosmetic results after central lumpectomy. In addition, remember that mastectomy is not necessarily a "better" operation - in most cases there is no long-term survival advantage to mastectomy compared to lumpectomy / radiation. Generally if there is retraction of the nipple, that is because there is cancer behind the nipple or areola, and it "draws" the nipple inwards. Depending on the exam and findings of the imaging studies (especially MRI), preserving the nipple and areola might not be possible. If the nipple and areola do need to be removed, sometimes a "central lumpectomy" can be performed - again this depends on the location and size of the tumor as well as the size and appearance of the overall breast. If a central lumpectomy is performed, radiation therapy will be needed, as with any lumpectomy. Radiation is generally not needed after mastectomy, unless there is a very large tumor, if there is invasion of tumor into the skin, or if multiple lymph nodes are involved by tumor.

I would make sure you get a good idea of the cosmetic results after central lumpectomy. In addition, remember that mastectomy is not necessarily a "better" operation - in most cases there is no long-term survival advantage to mastectomy compared to lumpectomy / radiation.

Here is some more information from the American Society of Clinical Oncology that might be helpful: http://www.cancer.net/patient/All+About+Cancer/Managing+the+Cost+of+Cancer+Care/Financial+Resources In our experience medical debt crisis is a large concerns for patients who contact Patient Advocate Foundation. Many cancer patients have inadequate insurance or none at all and due to affordability, pre-existing clauses or a multitude of other reasons find themselves in this situation upon diagnosis. Some of the areas a patient can explore depending on income, asset and qualifiers are to apply for governmental programs such as Medicaid and/or Medicare, obtaining charity care and/or financial assistance through medical facilities, and obtaining necessary medications through prescription assistance programs or other state/national medication assistance programs (www.needymeds.com). Patients can explore clinical trials as a feasible option for access to care as well. It is always important to explore insurance options such as enrolling in plans offered at their own place of employment or their spouses. Children now can remain enrolled or re-enroll in their parents plan up until age 26 under healthcare reform, explore high risk pools or pre-existing health insurance plans (www.pcip.gov) now mandated by healthcare reform in each state, guarantee issues plans, individual/group insurance, and COBRA options. Georgetown University has an excellent website, http://www.healthinsuranceinfo.net that is a state by state consumer guide on how to get and keep health insurance and addresses topics I outlined here.

If the patient is insured is underinsured meaning he/she has health insurance coverage but lacks the financial resources needed to cover out-of-pocket expenses for medical care. Or underinsured when access to medical services is inhibited as the direct result of insurance benefit exclusions the patient can follow the same options as listed above. If they are insured through an employer who offers more than one plan, they should consider switching their benefit plan to a better option come open enrollment or if there has a been a qualifying event. Also there are many co-pay relief programs available such as our own Co-Pay Relief (www.copays.org)that can offer financial relief to qualified patients.

PAF is here to provide support to any patient with cancer who has difficulty accessing care regardless of their insurance status. We can be reached at 800-532-5274.

Here is some additional information from the American Society of Clinical Oncology: http://www.cancer.net/patient/All+About+Cancer/Managing+the+Cost+of+Cancer+Care/Financial+Resources The impact on Medicare Part D as a result of healthcare reform provides the following relief, while small a stepping stone to the closure of the gap as anticipated in the year 2020. For this year (2011) manufacturer’s are to offer a 50% discount on brand name prescription drugs and 7% discount on generic prescription drugs. Over the next ten years, Medicare beneficiaries will receive additional savings on brand name and generic drugs until the coverage gap is closed in 2020.

I don’t have concrete evidence based on your message if the medication you have a large out of pocket expense is a result of a grandfathered drug under Part B or more common drug covered under Part D which you must elect to enroll. Either way if you have insurance coverage for the medication I would strongly encourage exploring co-pay relief programs such as our own Co-Pay Relief (www.copays.org) they offer a 12 months look back period if approved, which is especially helpful for money you are out of pocket currently. Other copay programs are Assistance Fund, Cancer Care, Chronic Disease Fund, Inc, Healthwell Foundation, Leukemia and Lymphoma Society, National Organization for Rare Disorders, Patient Access Network Foundation, Patient Advocate Foundation Co-Pay Relief, and Patient Services Incorporated. Qualifiers all vary based on disease, drug, income levels.

Depending on the household income and asset level you should look into programs such as the Medicare Savings Program, there are programs that help millions of people with Medicare save money each year. States have programs for people with limited income and resources that pay some or all of Medicare’s premiums and may pay Medicare deductibles and coinsurance. You can learn more by visiting www.medicare.gov See publication #10126. I have listed below each of the programs. These figures do change each year and can vary per state but the following are for 2011:

QMB- Qualified Medicare Beneficiary - Covers part A and B premiums, and other cost-sharing (like deductibles, coinsurance and co-payments)
• Individual Monthly Income limit $903.50
• Married Couple Monthly Income limit $1215.00
SLMB- Specified Low-Income Medicare Beneficiary -Covers part B premiums only
• Individual Monthly Income limit $1,083.00
• Married Couple Monthly Income limit $1,457.00
QI- Qualifying Individual- Covers part B premiums only
• Individual Monthly Income limit $1219.00
• Married Couple Monthly Income limit $1,640.00
QDWI- Qualified Disabled & Working Individuals-Covers part A premiums only
• Individual Monthly Income limit $1825.00
• Married Couple Monthly Income limit $2448.33

A government program is also available to discount the amount a beneficiary pays for their medications. Eligibility is based on income and assets.
Also referred to as the “Extra Help Program.” The 2011 Guidelines are listed below and help Medicare recipients with premiums, deductibles and co-pays/coinsurance.
• If your yearly earnings and resources are:
• $21,855 married w/resources <$25,010
• $16,245 single w/resources <12,510
• If you qualify, you can enroll into a Medicare part D plan at any time.
o Online at www.socialsecurity.gov
o See publication #11318-AA


Additionally, explore your state to see if they offer a prescription drug program (pays for premiums or discounts.) http://www.rxassist.org/patients/res-state-programs.cfm

You should always review your current Part D or Advantage plan coverage annual during open enrollment to see if you are enrolled in the best cost effective plan as well. PAF case managers are available to provide support as well. I hope this information was helpful.

I would reinforce some of the points made by 20questions - there are many options and one technique is absolutely not right for everyone. The best results are when reconstruction is done once (although it is not uncommon to need revisions or minor tweaks). Interview more than one plastic surgeon, and also make sure that they are not only experienced with cosmetic surgery, but post-mastectomy reconstruction surgery - a completely different procedure. a breast may be reconstructed from the patient's own tissue such as from the abdomen (e.g. a TRAM flap) or a patient may choose to wear a special mastectomy bra with a prosthesis.

Ask questions, know what medications you are receiving and why, and if possible, have a friend, family member, or other advocate with you to ask these questions if you are not able to. I recommend using a patient safety checklist.
1. Know what medication you are taking, the dosage, the generic and brand names, and understand why you are taking it.
2. Before medication is administered to you as a patient in the hospital, repeat your name, date of birth, your physician's name, your diagnosis, and the medications you are supposed to be taking.
3. Check to see if the medication that is about to be administered to you matches what you know. If something is unusual or different, ask questions and speak up in a polite manner.
If you are unable to implement these strategies, enlist a loved one to act as your advocate.
Medication mistakes are the most common medical errors, harming 1.5 million patients a year. You can prevent this simply by being your own watchdog and understanding which medications you are taking.

Here is some additional information regarding reconstruction, taken from the following website:
http://www.breastreconstruction.org/breast_reconstruction_insurance_coverage.html

"The Federal Women's Health and Cancer Rights Act of 1998 (WHCRA) contains important protections for women with breast cancer who choose to have breast reconstruction after a mastectomy. It was signed into law on October 21, 1998. The US Departments of Labor and Health and Human Services have oversight of this law.

Under the Women's Health Act, group health plans, insurance companies, and HMOs that offer mastectomy coverage must also provide coverage for reconstructive surgery after mastectomy. This coverage includes reconstruction of the breast removed by mastectomy, reconstruction of the other breast to produce a symmetrical appearance, breast prostheses, and treatment of physical complications at all stages of the mastectomy, including lymphedema (swelling that sometimes happens after treatment for breast cancer).

This law sets a federal floor so that women can obtain breast reconstruction following mastectomy even if they live in states that do not require insurance companies to provide this coverage." If you are wondering if your insurance will cover the plastic surgery procedures desired to restore your breast shape, size- the answers can be found in your insurance plan benefit booklet. Most large insurance companies consider lumpectomy a "partial mastectomy" and will extend benefits for breast reconstruction procedures. Lets take a look at the policy language from UHC published on their public website - Their policy Breast Reconstruction Following Mastectomy #B-SHO-004 - UHC Medicare Plans states:

Guidelines/Notes:
1. When a member elects breast reconstruction following a medically necessary mastectomy or lumpectomy, coverage is to be provided as determined through consultation between the attending physician and the member, and includes:

a.Reconstructive breast surgery of the affected breast
b.Surgery and reconstruction of the unaffected breast to produce a symmetrical appearance
c.External breast prosthesis
d.Initial breast implant
e.Replacement breast implants when medically necessary
f.Nipple tattoo for reconstructive purposes
g.Tissue expansion
h.Regional tissue transfer
i.Treatment of physical complications resulting from the mastectomy or lumpectomy, including lymphedema. Treatment for lymphedema may include:.................(there's more but this portion makes my point)

_________________________________________________________________________
Any plastic surgeons office who routinely offers reconstruction procedures should pre-determine benefits with your insurance company and be able to explain exactly what is covered and what your out of pocket cost will be once you have decided what type of procedure you would like to have. Know all of your options, go in to the plastic surgeons office with a list of questions and ask them all, they should be more than happy to help.

All the best,

Gail L.

Yoga has been around for thousands of years, yet we are still gathering data regarding the effectiveness for breast cancer patients, and indeed for all patients (we're all patients on some level - so this means for everyone!). Here is a research study conducted at the MD Anderson Cancer Center in Texas, which demonstrated how yoga impacted physical and mental parameters to improve the quality of life in breast cancer patients:
http://fyiliving.com/research/benefits-of-yoga-for-breast-cancer-patients-undergoing-radiotherapy/ As a behavioral health provider, I recommend yoga to anyone for many reasons.

1. It's physical activity that can be modified to fit any person's ability and fitness level. It's a way to get moving and to improve wellness. Just recently it was announced in a research study that being sedentary is even more detrimental than we thought. Thirty minutes a day does not appear to be enough if we sit for 8 or more hours a day at a job or at home. Getting moving often means weight loss and improved muscle tone which often translates into improved body image as those results are reflected visually. Improved energy level is also a result of increased activity, counter-intuitive as that seems! The less energy we use, the less we have as the body's metabolism ramps down to meet expected demands, and vice versa.

2. Yoga involves breath work. Many of us exhibit poor posture and develop poor breathing habits. We basically do not exhange enough air to be fully oxygenated. This puts stress on the body and means the body may not work at optimum level to repair itself. Specific yogic breathing techniques are good for reducing anxiety and preventing or managing panic attacks.

3. Yoga stretches muscles, providing even more stress reduction and relaxation effect. One of the greatest complications of aging is in the loss of flexibility and balance. Consistent yoga practice can actually elongate muscles and improve balance and stamina.

4. Yoga is a mental discipline. Mastering your focus on breathing, proper body alignment and holding poses will benefit you in other areas of your life that require mental focus on discipline. It's an important transferrable skill that can potentially benefit you any time. Developing mental discipline is often extremely important in pain management.

Depending on what type of plastic surgery you are interested in, there are often several options. If you have asymmetry as a result of the cancer surgery (the breasts are not even), often a reduction, lift, or implant placement can be performed on one side in order to achieve a better cosmetic result. If there is good symmetry but an increase in size is desired, augmentation with implants is an option. A reduction can also be performed if a decrease in size is desired.

It is important to understand that if you previously had a lumpectomy followed by radiation therapy, while your breast and skin may feel and look normal, radiation therapy causes damage to the blood supply to the skin and breast, and that damage can cause difficulty with healing for subsequent procedures. Make sure that your plastic surgeon has experience in working with patients that have had prior breast cancer surgery, not just experience with cosmetic surgery. Depending on what type of plastic surgery you are interested in, there are often several options. If you have asymmetry as a result of the cancer surgery (the breasts are not even), often a reduction, lift, or implant placement can be performed on one side in order to achieve a better cosmetic result. If there is good symmetry but an increase in size is desired, augmentation with implants is an option. A reduction can also be performed if a decrease in size is desired.

It is important to understand that if you previously had a lumpectomy followed by radiation therapy, while your breast and skin may feel and look normal, radiation therapy causes damage to the blood supply to the skin and breast, and that damage can cause difficulty with healing for subsequent procedures. Make sure that your plastic surgeon has experience in working with patients that have had prior breast cancer surgery, not just experience with cosmetic surgery.

The longer I take care of women with breast cancer, the more uncommon side effects I see! At least a few times a month I see women on tamoxifen or aromatase inhibitors with unusual complaints - complaints that we typically don't associate with the medications, and they get better when the medication is stopped. I think it is a difficult decision to stop tamoxifen or aromatase inhibitors both for the physician and for the patient, but quality of life is important, so I would encourage women to speak to their physicians about any unusual symptoms that they are experiencing, and work with your doctor to help either manage the symptoms, or discuss if stopping the drug is the right decision for you. I was on Tamoxifen before Femara. My biggest problems were nausea and joint aches and pains. I do not remember having any cough with it though. This is just my experience though.

While removing the healthy breast in general will not impact overall survival as mentioned above, having reconstruction of both breasts at the same time can lead to a better cosmetic result. Sometimes the psychological benefit to the patient in knowing that her risk of developing a new cancer is significantly reduced (after both breasts are removed) makes this the operation of choice. However it is a decision that should be made with a lot of thought and support. If the woman is young (i.e. pre-menopause) and has any family history of breast, ovarian or prostate cancer (on the maternal or paternal side of the family), she should consider genetic counseling and testing. Genetic testing can determine if she carries an inherited genetic mutation that caused her cancer. In that case, a bilateral mastecomy is recommended because her chances of getting cancer in the unaffected breast are very high.

Without seeing the pathology or other reports, I would suggest twice-yearly exams by your surgeon or oncologist, annual digital mammography for the unaffected breast, and consider MRI and ultrasound as well depending on breast density. Because breast MRI does get some of the chest wall in the images, it can possibly be used to evaluate for chest wall recurrence, although there are some studies suggesting that post-mastectomy MRI is not any better than a careful physical exam. Without seeing the pathology or other reports, I would suggest twice-yearly exams by your surgeon or oncologist, annual digital mammography for the unaffected breast, and consider MRI and ultrasound as well depending on breast density. Because breast MRI does get some of the chest wall in the images, it can possibly be used to evaluate for chest wall recurrence, although there are some studies suggesting that post-mastectomy MRI is not any better than a careful physical exam.

The mammogram controversy will not go away anytime soon. Elyn I agree 100% that mammograms do save lives. However I also agree with "Regrounding" - mammograms have limitations especially in young women and anyone with dense breast tissue. In addition, we do find some cancers that probably do not need to be found because they are so slow growing and indolent that they will not cause the woman any harm. However despite more sophisticated testing such as MammaPrint and Oncotype Dx scores, we still cannot say in an individual woman - are you at risk from your cancer or not? - so we treat most women regardless of how early they were diagnosed. And there is no question that we overtreat some women. But until we can predict exactly which tumors are going to cause problems, it will remain a discussion for the patient and her physician, and a balancing act between overtreatment and saving lives. I would encourage women to know their risk factors, get to know their bodies, and talk to their physicians. I'd like to answer this from a different approach. Mamograms save lives and the quality of lives (i.e. caught earlier, less surgery, less toxic treatments). My mother was diagnosed in 95, but it was not a mamo that found her cancer...by time it was found the cancer was not in her breast, it was in her nodes (no breast surgery was done, details uncertain). However, two of her four daughters felt that mamos were not worth the risk. It was not until I was diagnosed with early stage that they could fully apprecitate the benefits of mamogram, as it was mamo that found my cancer. Yes, I do understand and fear radiation, however, the cost is too great to pass up on screening. I am excited that thermography is becoming more widely recognized....hopefully in the future this will be an option for all. Please, I urge you...get screened.

more...Yes, I agree with both of you. I am not certain that early detection always saves lives, and I am sure that in many cases, the body might have been able to elimate the cancer cells naturally, without intervention. So yes, the debate goes on....and coming from a person who often refuses dental x-rays, I look forward to the day that prevention and "cures" do not increase our risk for disease. One thing I will say in support of early detection is that often the remedy does not require toxic chemo and damaging radiation, and the misery and damage that goes along with them. In the meantime, I hope we can guide women to make the best possible choices for prevention and detection.

The standard recommendations for breast cancer screening are annual mammogram, clinical breast exam (exam by your physician), and breast self-exam. All have limitations, and none are perfect. Screening mammography generally should begin at age 40, but may begin earlier in women with a family history of early breast cancer. The American Cancer Society and the American College of Radiology recommend yearly screening. I usually recommend that women try to obtain their mammograms at a facility offering digital mammography, which has been shown to improve the rate of cancer detection in younger women and in women with dense breast tissue. It is also important that the radiologist compare current with prior mammograms as the changes may be very subtle.

In young women, women with dense breast tissue, and women at high risk (such as BRCA 1 and 2 mutation carriers), ultrasound and MRI with mammography should be used. However ultrasound and MRI are not meant to be stand-alone screening tests.

It is important to remember that approximately 10-15% of breast cancers will not show up on a mammogram. Ask about your breast density (it is included in most mammogram reports) and know your family history - based on these factors, ask your physician if you should also get an ultrasound and/or MRI. And so not ignore something that you feel, even if you are told that your mammogram is "normal". Make sure any abnormality gets fully evaluated.

Finally, there are many unanswered questions about screening mammography, brought to light in the past year or so with the US Preventative Task Force recommendations to start screening at age 50. Concerns were for "false alarms", unnecessary procedures, and detection of some cancers that might not require treatment. However there is plenty of data demonstrating that screening mammography does reduce the risk of death from breast cancer, so I do continue to recommend annual screening starting at age 40 in most of my patients. Some of the controversy is addressed in the following ABC news story: http://bit.ly/jIVW1d The standard recommendations for breast cancer screening are annual mammogram, clinical breast exam (exam by your physician), and breast self-exam. All have limitations, and none are perfect. Screening mammography generally should begin at age 40, but may begin earlier in women with a family history of early breast cancer. The American Cancer Society and the American College of Radiology recommend yearly screening. I usually recommend that women try to obtain their mammograms at a facility offering digital mammography, which has been shown to improve the rate of cancer detection in younger women and in women with dense breast tissue. It is also important that the radiologist compare current with prior mammograms as the changes may be very subtle.

In young women, women with dense breast tissue, and women at high risk (such as BRCA 1 and 2 mutation carriers), ultrasound and MRI with mammography should be used. However ultrasound and MRI are not meant to be stand-alone screening tests.

It is important to remember that approximately 10-15% of breast cancers will not show up on a mammogram. Ask about your breast density (it is included in most mammogram reports) and know your family history - based on these factors, ask your physician if you should also get an ultrasound and/or MRI. And so not ignore something that you feel, even if you are told that your mammogram is "normal". Make sure any abnormality gets fully evaluated.

Finally, there are many unanswered questions about screening mammography, brought to light in the past year or so with the US Preventative Task Force recommendations to start screening at age 50. Concerns were for "false alarms", unnecessary procedures, and detection of some cancers that might not require treatment. However there is plenty of data demonstrating that screening mammography does reduce the risk of death from breast cancer, so I do continue to recommend annual screening starting at age 40 in most of my patients. Some of the controversy is addressed in the following ABC news story: http://bit.ly/jIVW1d

It is important to note that phyllodes tumors are often categorized as benign and malignant. Benign phyllodes tumors are more common, and the treatment is surgical excision with a clear margin. They can become quite large, and rarely, mastectomy is needed; most can be removed with a lumpectomy. They do have the potential to recur in the breast, but do not have the potential to metastasize or spread to other areas of the body, and no other treatment besides removal is recommended.

Malignant phyllodes tumors are fortunately much less common. As mentioned by knutter1, chemotherapy has not been shown to be effective, and the data regarding radiation therapy is limited, but radiation therapy might be beneficial in some cases. Phyllodes tumors are a rare sarcoma type of cancer that occures within the connective tissues of the breast. It is technically a soft tissue sarcoma but originates within the breast so in some respects and fortunately we are now also catagorized as breast cancer as well. For US Phyllodes survivors this is fortunate as we can now have coverages previously not available from insurance and orgizations as well as making it easier to locate other Phyllode survivors. This is very helpful when dealing with a rare cancer as there is little or no information on treatment options and so forth. Phyllodes is reported to rarely metastisize though will often reoccur in or near the previous location. Surgery is the main treatment for Phyllodes or PT's until recently, but there was a study done in NH by Dr. Barth that has indicated that radiation has reduced the reoccurance rate. Thus far chemotherapy has proved to be useless in treatment of PT but when there is mets. often the treatment will include chemo but as far as I know there has been no success in it's use. It is unfortnate but if the mets are in a location where they cannot be surgically removed the prognosis is not good.

Hi Nancy - from the surgeon's standpoint, here's some information - since the expanders have been in place, the "pocket" below the muscle and the skin should be stretched out so that often while there is some discomfort after exchange for the implants, it should not be nearly as painful as after the mastectomy with expander placement. Often times drainage tubes are not used (ask your surgeon about this - some do leave drains). I usually let my patients sleep in whatever position they are most comfortable in, and usually within a few weeks most are comfortable sleeping on their sides. The overall recovery should be much faster than the mastectomy and expander placement. I only had a single mastectomy but I was able to sleep on my side without discomfort before too long (and I did get an implant/augmentation on the other breast at the same time they replaced my mastectomy expander with the implant, so perhaps I have some idea). I can vouch for what Dr. Attai said, for me the initial pain after the expander was placed was worse than having the implants placed, and that makes sense because my plastic surgeon had to cut into the muscle to create that "pocket" for the expander. They don't have to do that again when they place the implant. I didn't even take pain pills after the implants were placed, Tylenol worked well enough. Recovery was quicker and easier. My plastic surgeon advised me to miss two weeks of work after both the mastectomy/stage 1 reconstruction (expander) and the stage 2 reconstruction when both breasts got implants. I had only one drainage tube after the second surgery (the first surgery required two), and it came out after only four days. Good luck!

Now more than ever, surgeons are paying attention to the overall cosmetic results of a lumpectomy. It is no longer good enough just to preserve the breast - the goal should be breast preservation with as normal a shape and contour as possible. Oncoplastic techniques which combine cancer and plastic surgical techniques, allow for removal of tumors and some "rearranging" of tissue to leave a more natural cosmetic result - sometimes a combined approach where the breast surgeon and plastic surgeon work together is an option as well. Incision placement is important - some areas of the breast heal and scar differently than others. Of course we're often limited by the location of the tumor - something we can't change.

The use of ultrasound in the operating room by the surgeon allows the surgeon to more precisely determine where the cancer is and the appropriate amount of tissue to remove, reducing the amount of normal breast tissue that is removed, and reducing the need to return to the operating room for additional surgery. Finally, some newer surgical tools have been developed - my favorite is the PEAK PlasmaBlade - it is an electrosurgical tool that allows me to dissect through tissue and seal blood vessels, but it generates less heat than our standard electrosurgical tools. This means less damage to normal tissue, and improved healing.

Do realize that despite all of these techniques, the treated breast may wind up being smaller than prior to surgery and radiation. Federal law requires that insurance companies cover reconstructive procedures to the unaffected breast if needed to restore symmetry. Now more than ever, surgeons are paying attention to the overall cosmetic results of a lumpectomy. It is no longer good enough just to preserve the breast - the goal should be breast preservation with as normal a shape and contour as possible. Oncoplastic techniques which combine cancer and plastic surgical techniques, allow for removal of tumors and some "rearranging" of tissue to leave a more natural cosmetic result - sometimes a combined approach where the breast surgeon and plastic surgeon work together is an option as well. Incision placement is important - some areas of the breast heal and scar differently than others. Of course we're often limited by the location of the tumor - something we can't change.

The use of ultrasound in the operating room by the surgeon allows the surgeon to more precisely determine where the cancer is and the appropriate amount of tissue to remove, reducing the amount of normal breast tissue that is removed, and reducing the need to return to the operating room for additional surgery. Finally, some newer surgical tools have been developed - my favorite is the PEAK PlasmaBlade - it is an electrosurgical tool that allows me to dissect through tissue and seal blood vessels, but it generates less heat than our standard electrosurgical tools. This means less damage to normal tissue, and improved healing.

Do realize that despite all of these techniques, the treated breast may wind up being smaller than prior to surgery and radiation. Federal law requires that insurance companies cover reconstructive procedures to the unaffected breast if needed to restore symmetry.

Radiation therapy is most commonly used after a breast-conserving lumpectomy - if the breast is not removed with mastectomy, a course of radiation therapy is required. There are a few cases where radiation is also needed after mastectomy. When used after lumpectomy, there are several ways that radiation can be administered. The most common is called "external beam, whole-breast" - typically 5 treatments a week are given for anywhere from 4-6 weeks. Each treatment is very short, and typical side effects are fatigue and possibly skin discoloration and peeling. A newer technique is known as "accelerated partial breast irradiation", or APBI. A catheter (tube) is placed into the breast after lumpectomy; radiation is delivered into the catheter using tiny "seeds", and this treatment is given twice a day, but for only 5 days. As the radiation is more concentrated just where the original cancer was, there is less potential for damage to normal breast tissue. Also because the treatment is given directly within the breast, there is very little potential for damage to the skin. A final method of treatment is intraoperative radiation therapy (IORT). A single dose of radiation is given at the time of the lumpectomy. However 2 problems right now with this technique is that the pathology results are not known at the time of radiation, and there is no long-term results yet. Sorry a lengthy answer but we have so many options! Radiation therapy is most commonly used after a breast-conserving lumpectomy - if the breast is not removed with mastectomy, a course of radiation therapy is required. There are a few cases where radiation is also needed after mastectomy. When used after lumpectomy, there are several ways that radiation can be administered. The most common is called "external beam, whole-breast" - typically 5 treatments a week are given for anywhere from 4-6 weeks. Each treatment is very short, and typical side effects are fatigue and possibly skin discoloration and peeling. A newer technique is known as "accelerated partial breast irradiation", or APBI. A catheter (tube) is placed into the breast after lumpectomy; radiation is delivered into the catheter using tiny "seeds", and this treatment is given twice a day, but for only 5 days. As the radiation is more concentrated just where the original cancer was, there is less potential for damage to normal breast tissue. Also because the treatment is given directly within the breast, there is very little potential for damage to the skin. A final method of treatment is intraoperative radiation therapy (IORT). A single dose of radiation is given at the time of the lumpectomy. However 2 problems right now with this technique is that the pathology results are not known at the time of radiation, and there is no long-term results yet. Sorry a lengthy answer but we have so many options!

When implants are placed for breast enhancement, mammograms are still performed as drbreastsurgery noted above. However if a mastectomy with implant reconstruction is performed, mammograms generally are not performed. MRI examinations are sometimes done in this situation to make sure there is no recurrence of cancer on the chest wall or muscle, and to check the implants (if they are silicone) to ensure that there is no leakage. it shouldn't make it more difficult, as mammograms can be performed well with implants. the techs have techniques to move the implants slightly, to allow the breast tissue to undergo mammography.

If it is possible to undergo the reconstruction at the time of the mastectomy, many patients prefer that option - as Suzanne said, one major surgery instead of two. It is often a big relief for a woman to be able to wake up from anesthesia after a mastectomy with something in place, even if additional procedures might be needed. Also, if immediate reconstruction is performed, the scarring might be less extensive. Of course every situation is different, and the decision to undergo immediate reconstruction needs to be made on a case-by-case basis after consultation with the breast surgeon, plastic surgeon, and radiation oncologist as stated above. If it is possible to undergo the reconstruction at the time of the mastectomy, many patients prefer that option - as Suzanne said, one major surgery instead of two. It is often a big relief for a woman to be able to wake up from anesthesia after a mastectomy with something in place, even if additional procedures might be needed. Also, if immediate reconstruction is performed, the scarring might be less extensive. Of course every situation is different, and the decision to undergo immediate reconstruction needs to be made on a case-by-case basis after consultation with the breast surgeon, plastic surgeon, and radiation oncologist as stated above.

Cryoablation is being used for breast cancer, just not as standard treatment at this time. Cryoablation refers to a technique where the tumor is frozen "in-situ" (within the breast); the body then reabsorbs the tumor and surgery is not required. It is a standard treatment in my practice for benign breast tumors (fibroadenomas) and is performed in the office under local anesthesia using just a very small skin nick instead of a larger scar. For breast cancers, there are several small studies suggesting that this treatment is effective. The American College of Surgeons Oncology Group has a national clinical trial evaluating cryoablation for the treatment of breast cancer - once this study is complete, we should have more information regarding how effective cryoablation will be for breast cancers, but it does appear to be a promising technology and may allow some women to be treated effectively without surgery. Cryoablation is being used for breast cancer, just not as standard treatment at this time. Cryoablation refers to a technique where the tumor is frozen "in-situ" (within the breast); the body then reabsorbs the tumor and surgery is not required. It is a standard treatment in my practice for benign breast tumors (fibroadenomas) and is performed in the office under local anesthesia using just a very small skin nick instead of a larger scar. For breast cancers, there are several small studies suggesting that this treatment is effective. The American College of Surgeons Oncology Group has a national clinical trial evaluating cryoablation for the treatment of breast cancer - once this study is complete, we should have more information regarding how effective cryoablation will be for breast cancers, but it does appear to be a promising technology and may allow some women to be treated effectively without surgery.

Thanks to early detection through screening mammography and self-exam, many women diagnosed with breast cancer have early-stage or small tumors. In these cases, breast conservation surgery, or lumpectomy, is definitely an option. The goal with a lumpectomy is to remove the tumor and a rim of normal tissue (the "margin") while preserving the cosmetic appearance of the breast as much as possible. Lumpectomy does need to be followed by a course of radiation therapy. It is important to note that there is no difference in long-term survival if a woman undergoes a lumpectomy versus mastectomy - lumpectomy with radiation therapy is a perfectly appropriate cancer treatment. Certain situations call for mastectomy for example very large cancers, or more than one cancer in the breast, but in many cases, breast conserving surgery is possible and is very appropriate. Thanks to early detection through screening mammography and self-exam, many women diagnosed with breast cancer have early-stage or small tumors. In these cases, breast conservation surgery, or lumpectomy, is definitely an option. The goal with a lumpectomy is to remove the tumor and a rim of normal tissue (the "margin") while preserving the cosmetic appearance of the breast as much as possible. Lumpectomy does need to be followed by a course of radiation therapy. It is important to note that there is no difference in long-term survival if a woman undergoes a lumpectomy versus mastectomy - lumpectomy with radiation therapy is a perfectly appropriate cancer treatment. Certain situations call for mastectomy for example very large cancers, or more than one cancer in the breast, but in many cases, breast conserving surgery is possible and is very appropriate.

CAM has been around for a long time but for many years has gotten a bad reputation as a poorly regulated and often dangerous area of medicine. Many physicians however recognize that traditional medicine does not have all of the answers, and there are many non-traditional therapies that are effective with minimal toxicity. Chinese and Ayurvedic therapies have been used successfully for thousands of years, and often a complementary or integrative approach incorporating some aspects of these therapies will result in more effective treatment. For example, in women undergoing chemotherapy for breast cancer, acupuncture, yoga/ tai-chi, meditation, and some herbal medications can provide support for the side effects. It is important to discuss CAM with your physician, as some herbal supplements can have significant side effects and interactions with prescription medication and treatment. However in general, there are many benefits to CAM, and patients should be encouraged to look into all of their options. CAM has been around for a long time but for many years has gotten a bad reputation as a poorly regulated and often dangerous area of medicine. Many physicians however recognize that traditional medicine does not have all of the answers, and there are many non-traditional therapies that are effective with minimal toxicity. Chinese and Ayurvedic therapies have been used successfully for thousands of years, and often a complementary or integrative approach incorporating some aspects of these therapies will result in more effective treatment. For example, in women undergoing chemotherapy for breast cancer, acupuncture, yoga/ tai-chi, meditation, and some herbal medications can provide support for the side effects. It is important to discuss CAM with your physician, as some herbal supplements can have significant side effects and interactions with prescription medication and treatment. However in general, there are many benefits to CAM, and patients should be encouraged to look into all of their options.

One problem with this procedure is that while the cosmetic results can be excellent, the nipple and surrounding skin often lose sensation as a result of the surgery, so that while the appearance is more natural, it does not feel the same as prior to surgery. Also if the patient also needs a "lift" at the time of the reconstruction, a nipple-sparing technique might not be the best option. It is also important to make sure your breast and plastic surgeon are experienced in this technique. nipple sparing mastectomies are a relative new option for women, and not all breast cancer surgeons believe that we have enough years of follow-up to offer it yet. it is not offered in all institutions. many surgeons still feel that the nipple needs to be removed to safely remove all breast tissue to excise as much breast tissue as possible and reduce the risk of recurrence.