Breast Cancer: Great Odds of a Cure

ightly or wrongly, breast cancer is the disease that women dread most. A woman's chances of developing heart disease are actually much higher. Other forms of cancer are equally devastating and harder to cure. But somehow it's still breast cancer that grips our attention.

Maybe it's because almost everyone knows someone who's had it. Or because it strikes many women in the prime of their lives. Whatever the reason, the raw statistics are frightening in themselves:

• Breast cancer hits 1 out of every 9 American women.
• There are 100,000 new cases each year; the majority are women between 40 and 70 years old.
• It is the leading cause of death in women aged 40 to 55 and causes more deaths than any other form of cancer from age 15 onward.

Now for the good news: Breast cancer has a very high cure rate—over 95 percent—when diagnosed early. Unfortunately, some women are so frightened of the “big C” that they don't call their physician even when they find a lump. Doctors can do much to fight this killer, but only if you give them the opportunity. It is impossible to overemphasize the importance of performing regular breast self­exams and getting regular mammograms during the high­risk years that surround menopause.

Whose Chances are Worst?

No one understands exactly why breast cancer seems to run in some families and not others, but physicians are getting better at predicting which of us is more likely to be stricken. Whatever the underlying reason may be, family history definitely does play a significant role. If your mother or sister—or both—have had breast cancer, your estimated risk is 10 to 15 times higher than that of a woman whose close female relatives are breast cancer­free. Breast cancer in a more distant relative, such as a cousin, is not currently considered to be a risk factor.

The older you are, the greater your chance of developing this frightening disease. Breast cancer rarely occurs before the age of 20. The odds of developing it gradually increase after that, leveling off for a bit after menopause, then starting to rise again at age 65. Many doctors now believe that age becomes a serious consideration after 40—particularly between ages 40 and 44—and again after 60.

The longer a woman remains fertile, the greater her chances of developing breast cancer. If you started having periods early (before the age of 12), stop having them late (after the age of 55), or have them for more than 30 years, you're in the high­risk group. Some doctors and medical researchers speculate that the factors that eventually trigger the development of breast cancer begin to work as soon as a girl enters puberty. The process continues until she reaches her early 40s.

Pregnancy seems to short­circuit the process under certain circumstances. The earlier a woman completes her first full­term pregnancy, the less likelihood she has of contracting the disease. For example, a woman's lifetime risk of developing breast cancer drops by as much as 70 percent when she has a baby before her eighteenth birthday. This beneficial effect steadily tapers off during her 20s and seems to vanish entirely by the time she reaches the age of 30.

Women who have their first baby after the age of 35 are twice as likely to develop breast cancer as those who give birth while still in their teens. As a matter of fact, postponing childbirth until your 30s seems to be more risky than never having a baby.

Although some reports seem to indicate that women with only one or two children are at a somewhat higher risk, having a large family will not reduce your odds of getting breast cancer. Nor does abortion play a significant role. And what of the widespread belief that breastfeeding naturally protects a nursing mother from breast cancer? At present, it's still under scientific debate.

Like early motherhood, the removal of the ovaries seems to offer some protection against breast cancer. If a woman's ovaries are surgically removed while she is still in her mid­to­late thirties, her chances of getting breast cancer can fall by as much as 75 percent. The risk­reducing benefits of this operation decline steadily as a woman nears the age of 40, then disappear entirely.

Other probable risk factors are harder to pinpoint. For example, breast cancer is most common among Caucasians and occurs much less often among Asians. But despite a very low rate of breast cancer among Japanese women who stay at home, the risk rises sharply among those who have moved to the United States—a phenomenon that has convinced some scientists of a link between environment and development of the disease.

Breast cancer also occurs more frequently among overweight women; city dwellers; and those who have previously had cancer of the (other) breast, ovary, or endometrium (the lining of the uterus). Women from high­ income families are also at greater risk, perhaps because they can afford to eat rich, fatty foods that can raise estrogen levels in the body. This female hormone is thought to promote the growth of a breast cancer once it gets started.

Because the breast is extremely vulnerable to the effects of radiation, previous exposure to radiation increases the odds of breast cancer, especially for women exposed before the age of 30. Exposure as a young girl is a particular cause for worry.

Your chances of getting breast cancer probably increase further with each additional risk factor you sustain, but experts are not sure by how much. If you have even one, the safest course is to have regular breast exams every 3 to 6 months, so that if a cancer does develop it can be stopped in time.

The Estrogen Connection

Researchers have spent decades investigating the role of the natural female hormone estrogen—and the oral contraceptive pills that contain it—in the development of breast cancer. After all these years, however, there's still no clear answer.

At present, the experts have no evidence that oral contraceptives trigger breast cancer (although estrogen has caused tumors in lab animals). A study conducted by the federal Centers for Disease Control and Prevention found that even high­risk women who had used oral contraceptives for long periods of time ran no greater risk of breast cancer than those who do not take the Pill. Indeed, some studies have found that oral contraceptives that combine estrogen with another hormone may actually offer some protection against breast cancer.

One clinician has noted that if the Pill did in fact promote breast cancer, we certainly should have seen an increase in the disease by now. There are, however, a couple of provisos. Doctors still advise caution for women over the age of 35, who are typically warned against using oral contraceptives anyway for a variety of other reasons, including the increased possibility of stroke. It's also believed that estrogen may hasten the development of an existing breast cancer in genetically susceptible women. And it has been found that, once breast cancer occurs, the hormone stimulates its growth in a significant percentage of women, particularly those who develop benign breast lesions after they begin taking estrogen supplements.

Surgical removal of the ovaries, which creates an artificial menopause and ends a woman's natural production of estrogen, markedly reduces her risk of developing breast cancer, especially if she is in her mid­thirties. About half of women with advanced breast cancer will go into remission after this procedure. (On the other hand, some other women have had a remission while taking estrogen.)

Warning Signs to Watch For

For nearly 80 percent of women with breast cancer, the discovery of a mass or lump in the breast is the first sign that something is amiss. Fortunately, 3 out of every 4 lumps discovered turn out to be noncancerous, but if you do find a suspicious lump, it's still best to call your doctor right away.

Most women discover breast lumps themselves, either by accident or while performing a monthly self­examination. Because early detection is crucial for a cure, you need to learn the right way to examine your breasts each month. The next chapter “Your Best Insurance Against Brest Cancer,” provides you with detailed instructions. Once you know the feel of a “normal” breast, you'll quickly recognize any little change.

Nearly half of all lumps appear at the top of the breast on the side nearest the armpit. For some reason the lumps occur in the left breast slightly more often than in the right. It is important to remember, though, that lumps can turn up anywhere within the breast, and that more than 20 percent of the time breast cancer is found when there's no lump at all.

If you do find a lump, your breast may be tender, or it may feel normal. There could be some discomfort or a “pulling sensation.” Cysts, which are benign, tend to move freely within the breast, so when a lump appears to be immobile, or the skin is dimpled or puckered, doctors tend to suspect that the growth is malignant. However, this is not a certainty.

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

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

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

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

Next Steps If You Find a Lump

If you notice a lump or anything else that seems suspicious, the next step will be an examination, followed by a mammogram and a biopsy.

Mammography

This well­known procedure is essentially an x­ray of the breast. It is an important weapon in the fight against breast cancer. Mammograms are invaluable not only for examining a known lump, but also for detecting lumps too small to feel. A tumor can keep growing for as long as 7 years before you or your doctor can feel it; and some masses buried deep within the breast or under the arm can be detected only by a mammogram. Without this procedure, such cancers can reach the dangerous stage before you even know about them. For more on mammography and its importance in regular cancer screening, turn to the next chapter.

Once a lump is discovered, by mammography or otherwise, your doctor can make a reasonable guess about the likelihood of malignancy based on the physical signs he or she finds during the examination. However, several other diseases have similar signs and symptoms, and a mammogram can only show the size and location of a mass. To be certain about a lump, only a biopsy will do.

Biopsy

All lumps are presumed guilty until proven innocent, even though nearly 4 out of 5 lumps are noncancerous. Any lump—and anything suspicious on a mammogram—is automatically a signal for a biopsy. Your physician will also recommend a biopsy if a nipple is inflamed, encrusted, or has scaly lesions that don't go away, or if it is leaking a bloody fluid.

If you haven't yet gone through menopause and you don't have any signs or symptoms that point to the possibility of cancer, your doctor may decide to wait through one complete menstrual cycle before proceeding. During this time he or she will check to see whether the lump goes away or is in any way affected by the hormonal changes that occur before, during, and after menstruation. On the other hand, if you have a history of cysts, or if the physician strongly suspects the mass is a relatively harmless cyst, he or she may do a needle biopsy right in the office.

This procedure, also known as fine needle aspiration, is fast, relatively painless and can help ease your anxiety if the lump is only a cyst and not a tumor. The doctor simply swabs the area with an antiseptic solution, then inserts a thin needle into the lump and draws off the fluid. The procedure can be done under local anesthesia.

A cyst is little more than a fluid­filled sac; a mass has more substance. The needle should have no trouble penetrating a cyst, but may encounter resistance if the lump is a solid mass and potentially malignant.

If the lump is really a cyst, the sac will collapse as soon as the fluid is removed, and the lump will suddenly disappear. In this case you will need a mammogram just to be sure, as well as another examination in 2 or 3 weeks. If the lump has not returned, there generally is no further cause for concern. However, a follow­up biopsy is needed if the doctor isn't able to get any fluid; if the fluid is bloody; if the mass does not completely disappear after the fluid is drawn; if the “cyst” returns after two “successful” aspirations; or if the mammogram is suspicious.

FINE NEEDLE ASPIRATION

This minor office procedure can quickly reveal whether a breast lump is a benign cyst or something more worrisome. To find out, the doctor inserts a thin needle into the lump and draws out the liquid contents. If the fluid is greenish or straw-colored, you're dealing with a harmless cyst. If it contains blood, further tests are needed: The doctor will smear a sample on a glass slide and send it to be examined for abnormal cells. The whole procedure takes only a few minutes, and requires no advance preparation.

Another possible procedure is a core needle biopsy, which uses a larger needle to take a sample of the mass. This approach, which does require local anesthesia, can be helpful for large tumors that might be difficult to remove in the office. However, a negative result could be misleading. In other words, even though the small sample contains no cancer cells, there's no guarantee that the entire mass is cancer­free.

If there is any doubt about the results of a needle biopsy, your doctor will order a surgical biopsy. This is necessary because the only way to be sure of the diagnosis is to look at the abnormal tissue under a microscope. If the lump is small—and your doctor feels it's not malignant—the surgeon will probably do an excisional biopsy, removing the entire mass. If the lump is larger, an incisional biopsy can be done instead. This procedure removes a small specimen from the mass, usually providing enough tissue for a diagnosis without having to make a large incision. However, if a diagnosis cannot be made without more tissue, the surgeon may decide to do an excisional biopsy and take the rest of the lump.

Biopsies are often performed on an outpatient basis. In the old days, the woman remained in the operating room while the pathologist examined the specimen. If the diagnosis was cancer, her breast was removed immediately. Clinical studies eventually showed that there was no need to do the biopsy and surgery in a single step. In the increasingly popular two­step approach, the biopsy is done at an outpatient clinic and surgery, if necessary, is performed in a hospital a week or so later.

A short delay between biopsy and surgery doesn't harm a woman's chance of survival, but does allow her time to discuss the proposed treatment and possible breast reconstruction with her physician. The doctor, in turn, has time to order a chest x­ray, blood tests, and other laboratory procedures that help determine whether the cancer has spread from the breast to the bones, lungs, liver or brain. If the cancer is localized, these test results can establish a baseline against which the doctor will compare follow­up tests done every three months after surgery.

The movement towards the two­step outpatient approach to biopsies has removed much of the fear that once kept women from seeking help when they felt a lump. In fact, as women take increased responsibility for their health care decisions, more and more of them are likely to request a biopsy. These women are no longer content with well­intended reassurances that the doctor is “almost 100 percent sure that there is nothing to worry about.” These women want answers that only a biopsy can provide.

Biopsy of a non­cancerous mass may also reveal the first signs of an early cancer in the surrounding “healthy” tissue. Without a doubt, biopsy remains the best­possible way to identify malignancies while the cancer is still highly curable.

Ultrasound

Ultrasound, another diagnostic tool, forms a picture by bouncing sound waves off the mass. Ultrasound takes longer to perform than a needle biopsy, and the results are generally not as good. However, it can be helpful in locating masses in younger women whose breasts are more dense and harder to see on a mammogram. Ultrasound is most useful in evaluating masses that lie deep within the breast and thus cannot be felt or reached with a needle.

Staging the Spread

With the diagnosis firmly established, the doctor is free to focus on determining whether the cancer has spread, and, if so, how far. This evaluation, or “staging,” involves ranking the cancer from Stage I (early cases) to Stage IV (advanced cases). For the precise description of each stage, see the box nearby. There is no single “best” operation or treatment for breast cancer. Much depends on whether the disease is localized (only in the breast) or disseminated (in other parts of the body as well). Unfortunately, it is often difficult to tell whether the cancer has spread. There is no definitive laboratory test for this, and many women don't have any symptoms at all.

Treatment: Assessing the Options

Prompt treatment is essential. Without surgery, radiation, or chemotherapy, a woman who has breast cancer will almost surely die. Fortunately, the chances for long­term survival—and cure—are excellent if the cancer is caught early enough.

Once the physician has determined the type of breast cancer, the size and location of the primary tumor, and the extent of the disease, it's time to discuss the various treatment options. The doctor will recommend the course of treatment that he or she believes will provide the best results with the fewest disabling side effects.

The goal of the therapy is to prevent the spread of cancer if the disease is confined to the breast and to minimize the possibility of a recurrence of cancer in the future. For women whose cancer has already spread, the physician will develop a treatment plan that eases any pain or other symptoms. This is called palliative therapy.

Mastectomy—surgical removal of the breast—offers a good chance of a cure for Stage I and II breast cancers. Surgery may also be successful for some Stage III cancers if they have not invaded other parts of the body. Women with Stage IV breast cancer receive palliative treatment.

Surgery

There are many different types of surgery for breast cancer—from removing just the lump to removing the entire breast and the muscles in the chest. The surgeon may also remove some—and possibly all—of the lymph nodes under the arm.

The lymph nodes are part of the body's lymphatic system, which filters waste from the tissues and carries fluids that help the body fight infection. The lymphatic system transports fluids very efficiently and, if invaded by cancer cells, can carry them throughout the body. Surgeons remove at least a sampling of the lymph nodes near the breast to check whether the cancer has reached the nodes. The extent of “nodal involvement”—the number of lymph nodes with cancer—helps the physician determine how much radiation or chemotherapy a woman needs after surgery.

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

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

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

Radical Mastectomy

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

Surgeons believed that removing the entire breast was the best way to get rid of all of the cancer—assuming that the disease hadn't yet spread beyond the breast. Taking out all the lymph nodes made it possible to better determine the extent of any spread.

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

Over the years, scientific studies have shown that removing the chest muscles doesn't improve a woman's prognosis and isn't necessary if the cancer is found early. Today, doctors seldom perform radical mastectomies.

FROM RADICAL TO MODIFIED RADICAL

Radical mastectomy, which removes both pectoral muscles along with the breast and lymph nodes, has been discredited in all but severe cases. A modified radical mastectomy, which leaves one or both muscles intact, is now considered just as effective in stopping the cancer's spread. With less muscle and nerve damage to contend with, women suffer fewer complications after the operation and find subsequent breast reconstruction to be less of a problem.

Modified Radical Mastectomy

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

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

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

Although many women don't decide to have reconstruction until several months or even years after their cancer surgery, it is important to discuss the possibility beforehand so that the surgeon can help prepare the area for eventual operation. The type of incision used in the mastectomy, for example, can make a big difference in subsequent reconstructive surgery.

If reconstruction seems likely, the plastic surgeon will probably advise having a modified radical mastectomy because this operation allows the best cosmetic result possible.

Some women still view any removal of the breast as mutilation, but in some cases, there is little choice if they want to survive. The National Cancer Institute continues to recommend breast removal for tumors larger than three­quarters of an inch.

Total or Simple Mastectomy

In this operation, the surgeon removes the breast and maybe a few of the lymph nodes closest to the breast. Presumably, any invasion of cancer cells will show up in these lymph nodes first. Radiation therapy may or may not follow the surgery.

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

The drawbacks, however, can be serious. The breast, of course, is still removed, and there is always the possibility that the cancer has already spread to some of the lymph nodes that have not been examined. In that case, the cancer will remain undiscovered until the disease has progressed much farther.

Partial or Segmental Mastectomy

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

OTHER OPTIONS

Three alternatives to modified radical mastectomy leave more of the breast area intact: Simple mastectomy stops with removal of the breast and, at most, a few nearby lymph nodes. There's less postoperative swelling, and reconstruction is easier. Partial mastectomy takes only a portion of the breast, as the name implies. However, the surgeon may also remove lymph nodes and a portion of the chest muscle's lining. Lumpectomy, the least damaging of all the options, focuses on the tumor, but may include lymph nodes as well. The operation leaves a scar, but can render reconstruction unnecessary. Doctors are still debating the effectiveness of these operations. Because a potentially cancerous lymph node may be left behind, radiation therapy is used as a backup precaution after a partial mastectomy or lumpectomy, and after some simple mastectomies as well.

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

Lumpectomy

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

There is much debate about a lumpectomy's effectiveness in comparison with more extensive surgery. Some physicians want to see more research on survival rates before they perform the procedure; others believe it can be a safe alternative to mastectomy. The National Cancer Institute does not advise a lumpectomy when the tumor is larger than three­quarters of an inch.

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

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

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

After Surgery: Reconstruction

It took a while, but physicians have come to realize that treating breast cancer involves more than just getting rid of the tumor. The psychological impact of losing a breast varies, but for many women it means some very real grieving. Doctors are learning to ask women whether they've considered reconstructive surgery, and women are learning to speak up.

Obviously, the medical team is most concerned with saving the woman's life. But if the surgeon knows that she eventually plans to have reconstruction, he can tailor the operation to help ensure a natural­looking result from future plastic surgery.

Many women prefer to have reconstruction immediately; others put it off for years. The decision to perform immediate reconstruction depends on many factors, including age, the size and location of the tumor, and the stage of the disease.

The benefits of having reconstructive surgery at the time of breast removal are obvious, and there is little evidence that the cosmetic surgery impedes successful treatment of the cancer. Doing the procedures back to back, however, does mean an additional two to seven hours of surgery and anesthesia.

Inserting a saline or silicone prosthesis into a pocket created in the breast takes much less time than transplanting tissue from the stomach. The plastic surgeon can also craft a new nipple and areola (the red area surrounding the nipple) if necessary. This latter procedure, which is done after the initial healing is completed, entails grafting tissue from the inner thigh or vagina.

If it is necessary to delay reconstruction during chemotherapy or radiation therapy, the surgeon can implant a small prosthesis at the time of breast removal. This temporary prosthesis helps stretch the skin and eliminates the need for excessive skin grafts when the full­sized prosthesis is eventually inserted.

Some women prefer to wear a breast prosthesis, that fits into a pocket in a custom­ designed brassiere. Many others, however, feel that surgical reconstruction makes them feel more attractive and normal.

Radiation's Role

Radiation therapy involves beaming x­rays at the site of the tumor to kill the growing cancer cells. X­rays may sterilize the tissue around the tumor site—and possibly under the arm—and keep the cancer from spreading or returning.

Although researchers are still studying the long­term success rate of radiation therapy, this treatment appears to be a promising option for early­stage cancer. Radiation is also used to shrink an especially large tumor prior to surgery or to slow the growth of inoperable tumors.

Radiation appears to be as effective as a mastectomy in treating early­stage cancer and unlike surgery, it lets a woman keep her breast; tissue surrounding the tumor generally remains undeformed. However, radiation is more often used following a lumpectomy than as a sole primary treatment.

There are two types of radiation. The doc-tor may beam a concentrated booster dose at the original tumor site or implant radioactive materials within the breast. The five­day­ a­week treatment usually lasts for five weeks.

Some women undergoing radiation develop a skin reaction similar to a sunburn and complain of itchy or peeling skin. However, the skin usually regains its normal appearance as soon as treatment ends. Radiation therapy may also cause a temporary decrease in the blood's disease­fighting white cells and increase the risk of developing an infection.

Follow­Up Treatment

In the past few years, physicians have recognized that adjutant (additional) treatment may improve the survival rate in early­stage breast cancer. A decade ago, it was assumed that women with no evidence of cancer in their lymph nodes went home after surgery and had a relatively good chance of remaining cancer­free with no further treatment.

Yet experience has shown that cancer does return in up to 30 percent of cases. And research over the past 75 years has consistently found that half of the women undergoing treatment for “curable” tumors never reach the 10­year survival milestone.

Since there is no way to be sure who is likely to have a recurrence, the National Cancer Institute now strongly recommends follow­up treatment with drugs (chemotherapy) or hormones to improve the odds of beating breast cancer. Doctors regard this “extra treatment” as an insurance policy, hopefully ridding the system of any hidden cancer that may remain and preventing or at least delaying any return of the disease.

Chemotherapy

If you have breast cancer, your doctor may prescribe a combination of drugs most likely to destroy remaining cancer cells. This anticancer “cocktail” is usually administered intravenously, generally every 3 to 4 weeks for anywhere from 4 to 24 months. Some drugs may be swallowed or injected into a muscle. At one time physicians used a single drug, but studies have shown that the various combinations are more effective.

Chemotherapy is generally recommended if there is any spread of the cancer—even to a single lymph node—because of the chance that surgery or radiation therapy will fail to eliminate all “residual” disease.

Radiation targets a specific part of the body. Chemotherapy, on the other hand, is a systemic treatment: The drugs reach every part of body. The strategy is to attack any remaining cancer cells no matter where the drugs are found.

The problem with this strategy is that the drugs are very strong. They attack many types of cells and, as a result, can produce debilitating side effects such as nausea, vomiting, fatigue, and hair loss. Because they can damage healthy cells, the body is less able to fight infections and other diseases.

Despite the drawbacks, chemotherapy works. Anticancer drug treatment can increase a woman's chance of reaching the 10­year survival mark by as much as 35 percent. If the disease has already spread, chemotherapy will generally shrink up to 60 percent of the tumors. About 20 percent of the women under treatment will have no sign of cancer after completing chemotherapy.

The even better news is that some of the newer drugs cause fewer and less severe side effects. Some women are lucky and don't have any side effects at all. Administering certain drugs before chemotherapy can help reduce nausea and vomiting, too. Regular laboratory tests can alert the doctor to any damaging effects on the body's ability to fight infection and other diseases.

Hormonal Therapy

It is not uncommon for cancer to return. It eventually recurs in up to half of the women who have surgery or radiation to treat the original tumor. Additional treatment with radiation or chemotherapy greatly improves a woman's odds against having a recurrence, but there are still no guarantees.

The possibility of a recurrence weighs heavily on anyone who has had breast cancer. Fortunately, there are some very promising new treatments. Hormonal therapy, for example, is proving to be particularly effective.

Studies indicate that some cancers need the female hormone estrogen (or sometimes progesterone) to grow. Pathologists now test the tissue removed at biopsy for the presence of estrogen receptors. If the tumor has these receptors, it means that the cancer is “receptive” to estrogen and probably will not grow as well or as quickly if deprived of the hormone.

This is pretty much how hormonal treatments work: They either block or eliminate a woman's natural supply of estrogen.

About two­thirds of women with breast cancer have estrogen­receptive tumors and can benefit from hormonal therapy. According to the National Cancer Institute, when a tumor has both estrogen and progesterone receptors, there is an 80 percent chance that the cancer will respond to hormone treatment.

Anti­estrogen treatment may involve removing the ovaries in women younger than 40 years of age. This operation effectively halts the body's estrogen production and produces a high rate of remission in younger women.

A drug called tamoxifen has also proved to be very effective, particularly in older women who have already completed menopause. Tamoxifen works by attaching itself to the estrogen receptors and blocking the estrogen from doing its cancer­promoting work. The drug is taken twice a day for up to 5 years.

Pregnancy and Breast Cancer

One out of every 35 women with breast cancer is also pregnant. Although the incidence of breast cancer found during pregnancy is lower (1 in 3,000), the implications are very serious—both for the mother and for her baby.

The overall breast cancer survival rate of 50 percent drops to 15 to 20 percent if the woman is pregnant. And although the generally poor prognosis improves greatly—climbing to a survival rate of 70 to 80 percent—if the cancer is caught early, unfortunately it rarely is. By the time the cancer is diagnosed, it has usually progressed to a stage that carries a much less favorable prognosis.

According to one theory, breast changes that occur naturally during pregnancy may obscure Stage 1 tumors. Another possibility is that increased hormonal activity during pregnancy may accelerate the natural progression of the disease. It's also thought that the increased blood supply to the breasts that occurs during pregnancy may help spread the cancer.

Although there currently is no hard evidence for the theory that pregnancy speeds the growth of tumors in the breast, and no proof that a therapeutic abortion improves a patient's prognosis, many physicians still suspect that pregnancy does play a role.

Treating breast cancer in a pregnant woman is problematic. Many of the drugs used in chemotherapy are known to harm a developing fetus; radiation therapy is similarly unwise because of the potential risk to the baby. The decision as to how best to treat the cancer can only be made after careful consideration of such variables as the length of the pregnancy, the extent of the cancer, the probable prognosis, and the wishes of the mother­to­be.

Women who develop breast cancer while pregnant should not breastfeed their babies. It is possible that both breasts could contain cancer and that the increased blood supply in a nursing mother's breast could help feed a growing tumor.

Although pregnancy before the age of 18 markedly reduces a woman's likelihood of developing breast cancer in the first place, there is no evidence that having a baby will protect a woman against a recurrence of breast cancer. On the other hand, there's also no evidence that a woman who has undergone breast cancer treatment before conceiving should terminate her pregnancy if there is no sign that the cancer has recurred.

Since breast cancer usually occurs in women over 35, it rarely affects expectant mothers. However, if you have had the disease and are considering becoming pregnant, talk to your family doctor or cancer specialist before making your final decision. He or she will help you determine if it is safe for you to have a child.

The Need for Follow­up Care

Follow­up care is crucial, especially during the first 5 years after the initial diagnosis. According to the National Cancer Institute, 60 percent of the recurrences of breast cancer appear in the first 3 years; another 20 percent happen in years 4 and 5. The remainder can show up from 5 to 20 years later.

If you've had breast cancer, your physician will schedule regular office visits to examine your breasts, scars, chest, underarms, and neck. From time to time, the doctor will perform a complete physical examination and order a mammogram. Every 3 months or so, there will be a battery of blood and urine tests to make sure there is no sign of cancer in other parts of the body. Because breast cancer is most likely to travel to the lungs, bones, and liver, periodic chest x­rays and bone and liver scans will also be necessary.

The physical healing after breast cancer treatment takes a few weeks. The psychological scars take much longer. Many women find that it helps to meet with other cancer survivors who truly understand the fear and anger that can follow a diagnosis of breast cancer. They cope by learning to live in the present and not dwell on the unknown. And, like all women, they can take comfort in the steadily growing number of women who have fought the disease and survived.

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