Most kinds of cancer are named after the part of the body where the cancer first starts. Breast cancer begins in the breast tissue. This article refers only to breast cancer in women. Men can also get breast cancer, although this is rare. A separate document on male breast cancer is available from the American Cancer Society.

Inside the breasts are glands that produce and release milk after a woman has a baby. The glands that make the milk are called lobules and the tubes that connect them to the nipple are called ducts. The breast itself is made up of lobules, ducts, and fatty, connective, and lymphatic tissue.

Lymph is a clear fluid that contains immune system cells. The fluid is carried in lymph vessels that lead to small, pea-sized collections of tissue called lymph nodes. Most lymphatic vessels of the breast lead to lymph nodes under the arm. They are called axillary nodes.

If breast cancer cells reach the underarm lymph nodes, they can continue to grow, causing the nodes to swell. When cancer cells have reached these nodes, they are more likely to spread to other organs of the body as well.

There are several types of breast tumors. Most are benign; that is, they are not cancer. These lumps are often caused by fibrocystic changes. Cysts are fluid-filled sacs, and fibrosis refers to the forming of connective tissue or scar tissue. Fibrocystic changes can cause breast swelling and pain. The breasts may feel lumpy and sometimes there is a clear or slightly cloudy nipple discharge. Benign breast tumors are abnormal growths, but they do not spread outside of the breast and they are not life threatening.

Breast cancer, on the other hand, involves malignant tumors. Here are some terms that describe the most common types of breast cancer:

Ductal carcinoma in situ (DCIS): This is breast cancer at its earliest stage (stage 0). It is confined to the ducts. Nearly 100% of women with cancer at this stage can be cured. The best way to find DCIS is with a mammogram.

Infiltrating (invasive) ductal carcinoma (IDC): This cancer starts in a milk passage or duct, breaks through the wall of the duct, and invades the fatty tissue of the breast. From there it can spread to other parts of the body. IDC is the most common type of breast cancer. It accounts for nearly 80% of breast cancer.

Lobular carcinoma in situ (LCIS): A tumor that hasn't spread beyond the area where it began is called in situ. Although not a true cancer, LCIS increases a woman's risk of developing cancer later. For this reason, it's important for women with LCIS to have a physical exam two or three times a year, as well as a mammogram every year.

Infiltrating (invasive) lobular carcinoma (ILC): This cancer starts in the milk glands (lobules). It can spread to other parts of the body. Between 10% and 15% of breast cancers are of this type.

How Many Women Get Breast Cancer?

Breast cancer is the most common cancer among women, other than skin cancer. It is the second leading cause of cancer death in women, after lung cancer.

The American Cancer Society predicts that there will be about 182,800 new cases of invasive breast cancer in the year 2000 among women in this country and about 40,800 deaths from the disease. Breast cancer also occurs among men, although much less often.

Death rates from breast cancer declined significantly during 1992 to 1996, with the largest decrease in younger women-- both white and black. This decline is probably the result of better detection and improved treatment.

What Causes Breast Cancer?

We do not yet know exactly what causes breast cancer, but we do know that certain risk factors are linked to the disease. A risk factor is something that increases a person's chance of getting a disease. Different cancers have different risk factors. Some risk factors, such as smoking, can be controlled. Others, like a person's age or family history, can't be changed. While all women are at risk for breast cancer, the factors listed below can increase the chances of a woman's having the disease.

Gender: Simply being a woman is the main risk factor for breast cancer. Men can get breast cancer, but this is fairly rare.

Age: the chance of getting breast cancer goes up as a woman gets older.

Genetic risk factors: Between 5% and 10% of breast cancers appear to be linked to changes (mutations) in certain genes. Studies show that some breast cancer is linked to changes of the BRCA1 and BRCA2 genes. If a woman has inherited a mutated gene from either parent, she is more likely to develop breast cancer. About 50%-60% of women with these inherited changes will develop breast cancer by the age of 70.

Family history: Breast cancer risk is higher among women whose close blood relatives have this disease. The relatives can be from either the mother's or father's side of the family. Having a mother, sister, or daughter with breast cancer almost doubles a woman's risk.

Personal history of breast cancer: A woman with cancer in one breast has a greater chance of developing a new cancer in the other breast. This is different from a recurrence of the first cancer.

Race: White women are slightly more likely to develop breast cancer than are African-American women. But African-Americans are more likely to die of this cancer. Asian and Hispanic women have a lower risk of developing breast cancer.

History of radiation treatment: Women who have had chest area radiation treatment as a child or young woman have a significantly increased risk of breast cancer.

History of breast biopsy: Certain types of abnormal biopsy results can be linked to a slightly higher risk of breast cancer.

Menstrual periods: Women who began having periods early (before 12 years of age) or who went through the change of life (menopause) after the age of 50 have a small increased risk of breast cancer. The same is true for women who have not had children, or who had their first child after they were 30 years old.

Birth control pills: It is still not clear what part birth control pills might play in breast cancer risk. A recent study found that women using birth control pills have a slightly greater risk of breast cancer. Women who stopped using the pill more than ten years ago do not seem to have any increased risk. Women should discuss the risks and benefits of birth control pills with their doctor.

Estrogen replacement therapy (ERT): Some studies suggest that long-term use (10 years or more) of estrogen replacement therapy (sometimes called hormone replacement therapy) for relief of menopause symptoms may slightly increase the risk of breast cancer.

A recent study found that the long term use of both estrogen and progestin may increase the risk of breast cancer when compared to the risk for women using estrogen alone. This risk applies only to current and recent users. A woman's breast cancer risk returns to that of the general population within 5 years of stopping ERT.

Replacement therapy also lowers the risk of heart attacks and bone fractures; therefore, women should talk to their doctors about the pros and cons of using ERT.

Not breast feeding: Some studies suggest that breast feeding, if continued for 1 1/2 to two years, may slightly lower breast cancer risk. Other studies found no impact on breast cancer.

Alcohol: Use of alcohol is clearly linked to increased risk of developing breast cancer. Women who have one alcoholic drink a day have a very small increased risk. Those who have 2 to 5 drinks daily have about 1.5 times the risk of women who drink no alcohol. The American Cancer Society recommends limiting the amount you drink, if you drink at all.

Diet: There may be a link between being overweight and a higher risk of breast cancer, especially for women after menopause. But the connection between weight and breast cancer risk is complex. For example, risk appears to be higher for women who gained weight as adults, but not for those who have been overweight since childhood.

Studies of fat in the diet as it relates to breast cancer risk have often given conflicting results. Many studies of women in the United States have not found breast cancer risk to be related to fat in the diet. On the other hand, there is evidence that breast cancer is less common in countries where the typical diet is low in fat. More studies are needed to clarify the impact of fat intake and body weight on breast cancer risk. But, since diet and weight have been shown to affect the risk of developing several other types of cancer and heart disease, the American Cancer Society recommends maintaining a healthy weight and limiting your use of high-fat foods, especially those from animal sources.

Exercise: Exercise and cancer is a fairly new area of research. Some studies suggest that exercise in youth might give life-long protection against breast cancer. Even moderate physical activity as an adult could lower breast cancer risk. More research is being done to confirm these findings.

Induced abortion: A large, recent study indicated that induced abortions do not increase the risk of breast cancer. Also, most studies also show no direct link between miscarriages and breast cancer.

Smoking: While a direct link between smoking and breast cancer has not been found, smoking affects overall health and increases the risk for many other cancers, as well as heart disease. Women who smoke should make every attempt to quit.

Environment: Right now, research does not clearly show a link between breast cancer risk and exposure to pollutants such as pesticides. A great deal of research has been reported and more is under way in this area.

Antiperspirants and bras: Recent internet e-mail rumors have suggested that underarm antiperspirants and underwire bras hamper lymph circulation and increase the risk of breast cancer. There is no evidence to support this idea.

Can Breast Cancer Be Prevented?

Although we know some of the risk factors linked to breast cancer, we do not yet know what causes most breast cancer. Therefore, at this time, there is no certain way to prevent breast cancer. For now, the best strategy is to reduce risk factors whenever possible and follow the guidelines for finding breast cancer early.

Genetic testing can tell if a woman has certain mutated genes, but it cannot predict whether a woman will get breast cancer. This is not a test for all women. Talk to your doctor if you have a history of breast cancer in your family. Genetic testing is expensive and is not covered by some health plans. People with positive results might not be able to get insurance, or coverage might only be available at a much higher cost. You need to weigh carefully the benefits and the drawbacks before you proceed with testing.

The drug Tamoxifen has been used for many years as a treatment for some breast cancer. Recent studies show that women at high risk for breast cancer are less likely to develop the disease if they take Tamoxifen. But some researches believe it is still not clear whether the drug prevents cancer or whether it works by treating small cancers that were not known to be present.

Another drug, Raloxifene, also blocks the effect of estrogen on breast tissue and some studies seem to show that it lowers the risk of breast cancer. But Raloxifene has not yet been approved for this use.

In some rare cases, women at very high risk of breast cancer might consider a preventive (prophylactic) mastectomy. This is an operation in which one or both breasts are removed before there is any known breast cancer. The reasons for considering this type of surgery need to be very strong. These reasons would include one or more of the following: inherited mutated genes, an earlier breast cancer, a strong family history of breast cancer, and diagnosis of certain conditions such as lobular carcinoma in situ.

While the operation reduces the risk of breast cancer, it does not guarantee that cancer won't develop in the small amount of breast tissue remaining after the operation. Clearly this is something a woman should discuss carefully with her doctor. A second opinion is also strongly recommended.

How Is Breast Cancer Found?

The earlier breast cancer is found, the better the chances for successful treatment. The American Cancer Society recommends the following guidelines for finding breast cancer early:

• A mammogram and a breast exam by a doctor or nurse (clinical breast examination) every year for women over the age of 40.
• Between the ages of 20 and 39, women should have a clinical breast exam every 3 years.
• All women over 20 should do breast self- examination (BSE) every month.

Together, these methods offer the best chance of finding breast cancer early. Each is covered in more detail below.

Mammography

A mammogram is an x-ray of the breast. A mammogram can be used to find breast disease in women who already have symptoms. Screening mammography, on the other hand, is used to look for breast disease in women who appear to have no breast problems.

During mammography, the breast is squeezed between two plates for a few seconds while pictures are taken. Very low levels of radiation are used. While many people are worried about exposure to x-rays, the low level of radiation used for mammograms does not greatly increase the risk of breast cancer. For example, a woman who has radiation as treatment for breast cancer will receive several thousands rads, the unit that measures radiation. If a woman has yearly mammograms beginning at age 40 and continuing until she is 90, she will have received only 10 rads.

A mammogram alone cannot prove that an area of concern is breast cancer. To confirm whether cancer is present, a small amount of tissue must be removed and examined under a microscope. This procedure is called a biopsy and is covered in more detail later in this article.

Clinical Breast Examination

You should have a breast exam by a doctor, nurse, or other health professional every year if you are 40 or over. If you are between 20 and 39, you should have this exam every three years. The doctor will first examine the breasts for any changes in shape or size and then gently feel the breasts, and also examine the area under both arms. This is a good time for the doctor or nurse to teach you breast self-examination if you don't already know how to do it.

Breast Self Examination (BSE)

The best time to do BSE is about a week after your period ends, when your breasts are not swollen or tender. If you are not having regular periods, do BSE on the same day every month.

• Lie down with a pillow under your right shoulder and place your right arm behind your head.
• Use the finger pads of the three middle fingers on your left hand to feel for lumps in the right breast.
• Press firmly enough to know how your breast feels. A firm ridge in the lower curve of each breast is normal. If you're not sure how hard to press, talk to your doctor or nurse.
• Move around the breast in a circular, up and down line, or wedge pattern. Be sure to do it the same way every time, check the entire breast area, and remember how your breast feels from month to month.
• Repeat the exam on your left breast, using the finger pads of the right hand. (Move the pillow to under your left shoulder.)
• If you find any changes, see your doctor right away.
• Repeat the examination of both breasts while standing, with your one arm behind your head. The upright position makes it easier to check the upper and outer part of the breasts (toward your armpit). This is where about half of breast cancers are found. You may want to do the standing part of the BSE while you are in the shower. Some breast changes can be felt more easily when your skin is wet and soapy.
• For added safety, you can check your breasts for any dimpling of the skin, changes in the nipple, redness, or swelling while standing in front of a mirror right after your BSE each month.

Signs and Symptoms of Breast Cancer

The most common sign of breast cancer is a new lump or mass. A lump that is painless, hard, and has irregular edges is more likely to be cancer. But some cancers are tender, soft, and rounded. So it's important to have anything unusual checked by your doctor.

Other signs of breast cancer include the following:

• a swelling of part of the breast
• skin irritation or dimpling
• nipple pain or the nipple turning inward
• redness or scaliness of the nipple or breast skin
• a discharge other than breast milk

If Cancer is Suspected

If something unusual is found on your mammogram, or if you or your doctor finds a breast lump, other tests will need to be done to find out if cancer is really present. After taking your medical history and doing a thorough physical exam, including a clinical breast exam, your doctor may suggest a diagnostic mammogram and/or breast ultrasound. These imaging tests can sometimes tell if a lump is benign.

A ductogram is a test that is sometimes helpful in finding the cause of a nipple discharge. If there is a discharge, some of the fluid may be collected and examined under a microscope to see if any cancer cells are present.

The only way to know for sure if you have breast cancer is to do a biopsy. During a biopsy, cells from the breast are removed so they can be studied in the lab. There are several kinds of biopsies. In some, a very thin needle is used to draw fluid and cells from the lump. Other methods use a larger needle or surgery to remove more tissue. Ask your doctor which kind of biopsy will be done and what you can expect during and after the procedure.

In the past a woman was usually given general anesthesia and the biopsy was done while she was asleep. If cancer were found, the doctor went ahead with treatment such as mastectomy. The woman did not know until she woke up whether her breast had been removed.

Today, if cancer is found, a 2-step approach is almost always used. A biopsy is done first, followed by a decision concerning treatment. The biopsy can be done in the doctor's office or on an outpatient basis in the hospital. The woman then has time to talk to her doctor and family before deciding on a course of treatment.

The tissue removed during the biopsy is examined in the lab to see whether the cancer is invasive or not. The biopsy is also used to decide the type of cancer present. These types of breast cancer were covered in the section on "What is Breast Cancer?"

The biopsy sample is also given a grade. The grade helps predict the outcome (prognosis) for the woman because cancers that closely resemble normal breast tissue tend to grow and spread more slowly. In general, a lower grade number means a slower-growing cancer, while a higher number means a faster-growing cancer.

The biopsy sample can also be tested to see whether it has receptors for certain hormones such as estrogen and progesterone. If it does, it is often referred to as ER-positive or PR-positive. Such cancers tend to have a better outlook than cancers without these receptors and are much more likely to respond to hormonal therapy (see "How is Breast Cancer Treated?"). There are several other tests used to help predict how fast the cancer is growing.

Staging is the process of finding out how far the cancer has spread. This is very important because your treatment and the outlook for your recovery depend on the stage of your cancer. There is more than one system for staging cancer. The staging system of the American Joint Committee on Cancer (AJCC), also known as the TNM system, is the one used most often for breast cancer. It is described below.

The TNM system for staging gives three key pieces of information:

The letter T followed by a number from 0 to 4 describes the tumor's size and spread to the skin or chest wall under the breast. A higher number means a larger tumor and/or more spread to tissues near the breast.

The letter N, followed by a number from 0 to 3, shows whether the cancer has spread to lymph nodes near the breast and, if so, whether the affected nodes are attached (fixed) to other structures under the arm.

The letter M, followed by a 0 or 1, shows whether the cancer has spread (metastasized) to other organs of the body or to lymph nodes that are not next to the breast.

To make this information somewhat clearer, the TNM descriptions can be grouped together into a simpler set of stages, labeled stage 0 through stage IV (0-4).

In general, the lower the number, the less the cancer has spread. A higher number, such as stage IV (4), means a more serious cancer.

After looking at your test results, the doctor will tell you the stage of your cancer. Be sure to ask your doctor to explain your stage in a way you understand. This will help you both decide on the best treatment for you.

Breast Cancer Survival by Stage

The 5-year relative survival rate is the percentage of patients who are alive 5 years after diagnosis. Of course, patients might live more than 5 years after diagnosis. And these 5-year survival rates are based on women with breast cancer first treated more than 5 years ago. Women treated today may have a more favorable outlook.

Stage 5-year relative survival rate

0 100%
I 98%
IIA 88%
IIB 76%
IIIA 56%
IIIB 49%
IV 16%

How Is Breast Cancer Treated?

There is a lot for you to think about when choosing the best way to treat or manage your cancer. There may be more than one treatment to choose from. You may feel that you need to make a decision quickly. But give yourself time to absorb the information you have learned. Talk to your doctor. Look at the list of questions at the end of this piece to get some ideas. Then add your own.

You may want to get a second opinion. Your doctor should not mind your doing this. In fact, some insurance companies require you to get a second opinion. You may not need to have tests done again since the results can often be sent to the second doctor. If you are in an HMO (health maintenance organization), find out about their policy concerning second opinions.

This section provides a summary of the types of treatments available to women with breast cancer. The information in this article is not, however, official policy of the American Cancer Society and it is not intended as medical advice to replace the judgment of your cancer care team. It is meant to help you and your family make informed decisions, together with your cancer care team. Don't hesitate to ask them questions about your treatment options and to seek out information about treatment options from other reliable sources.

Each type of treatment has benefits and drawbacks. There may be side effects. Your age, your overall health, and the stage of your cancer are all factors to consider. If you would like to talk to another woman who has had breast cancer, the American Cancer Society can connect you with a volunteer in the Reach to Recovery program. Visits may be face to face, or via phone. Visitors are trained to provide current information, both before and after treatment. To learn more about Reach to Recovery or to request a visit, call the American Cancer Society at 1-800-ACS-2345.

Surgery, radiation therapy, hormone therapy, and chemotherapy are the most common treatments for breast cancer. In addition, you may hear about autologous stem cell or bone marrow transplantation and immunotherapy. All of these treatments are explained in more detail below.

Local and Systemic Therapy

The purpose of local therapy is to treat the main (primary) breast tumor. Surgery and radiation therapy are examples of local therapies. Systemic therapy is given through the bloodstream to reach cancer cells that may have spread beyond the breast. Chemotherapy, hormonal therapy, and immunotherapy are systemic therapies.

Surgery

Most women with breast cancer will have some type of surgery. The purpose of surgery is to remove as much of the cancer as possible. Surgery may also be combined with other treatments like chemotherapy, hormone therapy, or radiation therapy.

Surgery may also be done to find out whether breast cancer has spread to the lymph nodes under the arm (axillary dissection), to restore a more normal appearance (reconstructive surgery), or to relieve symptoms of advanced cancer. Below are some of the common types of breast cancer surgery:

Lumpectomy: Removal of only the breast lump and a rim of normal tissue. Lumpectomy is almost always followed by about six weeks of radiation therapy.

Partial mastectomy: Removal of up to one-quarter or more of the breast. Six to seven weeks of external beam radiation therapy is usually given following this surgery. For most women with breast cancer, lumpectomy or partial mastectomy is as effective as mastectomy. There is no difference in survival rates of women treated with these two approaches. Other factors, though, can affect which type of surgery is best for a woman.

Simple or total mastectomy: In this surgery the entire breast is removed but not the lymph nodes from under the arm nor muscle tissue from beneath the breast.

Modified radical mastectomy: Removal of the entire breast and some of the lymph nodes under the arm.

Radical mastectomy: Extensive removal of entire breast, lymph nodes, and the chest wall muscles under the breast. This surgery is rarely done now because modified radical mastectomy has proven to be just as effective with less disfigurement and fewer side effects.

Axillary Dissection: Removal of underarm (axillary) lymph nodes to find out whether the cancer has spread to these nodes. Knowing whether there are cancer cells in the lymph nodes can help guide other treatment decisions.

A possible side effect of removing these lymph nodes is swelling of the arm, called lymphedema. It happens to 1 or 2 women out of ten with breast cancer. Women who have swelling, tightness, or pain in the arm after lymph node surgery should be sure to tell their doctor right away. Often there are measures to prevent or reduce the effects of the swelling.

Sentinel lymph node biopsy: in this procedure, a radioactive substance or a dye is injected into the region of the tumor. The substance is carried by the lymph system to the first (sentinel) node to receive lymph form the tumor. This node is the one most likely to contain cancer cells if the cancer has spread. If the sentinel node contains cancer, more lymph nodes are removed. If it is free of cancer, further lymph node surgery might not be needed.

Reconstructive or breast implant surgery: These procedures do not treat the cancer. They are done to restore normal appearance after mastectomy. If you are having a mastectomy and are thinking about reconstruction, you should talk to a plastic surgeon before your operation. There are several choices about when the surgery can be done and exactly what type it will be.

You can contact the American Cancer Society for more detailed information about each of these types of surgery, their possible side effects, and breast forms and bras for use after surgery.

Chemotherapy

Chemotherapy refers to the use of drugs to kill cancer cells. Usually the drugs are given into a vein or by mouth. Once the drugs enter the bloodstream, they reach all parts of the body. If chemotherapy is given after surgery (adjuvant therapy) it can reduce the chance of breast cancer coming back. Chemotherapy can also be used as the main treatment for women whose cancer is widespread when it is found or spreads widely after initial treatment.

Neoadjuvant chemotherapy means that it is given before surgery, often to shrink the tumor to make it easier to remove. Another advantage of neoadjuvant chemotherapy is that the doctors can watch how the tumor responds to the drugs. If the tumor does not shrink, different drugs can be used.

Chemotherapy is given in cycles, with each period of treatment followed by a recovery period. The total course lasts three to six months. It is often more effective to use several drugs rather than a single drug alone. The most commonly used combinations are:

• cyclophosphamide, methotrexate, and fluorouracil (CMF)
• cyclophosphamide, doxorubicin (Adriamycin), and fluorouracil (CAF)
• doxorubicin (Adriamycin) and cyclophosphamide (AC), with or without paclitaxel (Taxol)
• doxorubicin (Adriamycin), followed by CMF

The side effects of chemotherapy depend on the type of drugs, the amount taken, and the length of treatment. Temporary side effects might include the following:

• nausea and vomiting
• loss of appetite
• hair loss
• mouth sores
• changes in menstrual cycle
• a higher risk of infection caused by a shortage of white blood cells
• bruising or bleeding
• fatigue

Most of these side effects go away when treatment is over. Anyone who has problems with side effects should talk with their doctor or nurse as there are often ways to help.

Radiation therapy

Radiation therapy is treatment with high energy rays (such as x-rays) to kill or shrink cancer cells. The radiation may come from outside the body (external radiation) or from radioactive materials placed directly in the tumor (internal or implant radiation).

Most often, external radiation is used for treating breast cancer. It is much like getting a regular x-ray, but for a longer period of time. Patients are usually treated five days per week in an outpatient center over a period of about six weeks. Each treatment lasts a few minutes. The treatment itself is painless. Radiation therapy may be used to reduce the size of a tumor before surgery or to destroy cancer cells remaining in the breast, chest wall, or underarm area after surgery.

The main side effects of radiation therapy are swelling and heaviness in the breast, sunburn-like changes in the treated area, and possibly fatigue. These changes to the breast tissue and skin usually go away in 6-12 months. In some women, the breast becomes smaller and firmer after radiation therapy. Radiation therapy is usually not given during pregnancy because it can be harmful to the fetus.

Hormone therapy

The female hormone estrogen can increase the growth of breast cancer cells in some women. A drug such as Tamoxifen, which blocks the effect of estrogen, is given to counter this growth. Tamoxifen is taken in pill form, usually for five years. Recent studies have clearly shown that women with early breast cancer are helped by this drug regardless of their age.

There are several other drugs that are sometimes used to block the effects of estrogen. Be sure to ask your doctor about the side effects of any hormonal drugs you are taking.

Another drug, Raloxifene, also blocks the effect of estrogen on breast tissue and breast cancer. It is now being tested to see if it can reduce a woman's risk of developing breast cancer. At this time it is not recommend as hormonal therapy for women who already have breast cancer.

Autologous Bone Marrow Transplantation or Peripheral Blood Stem Cell Transplantation

While it is possible to use very high doses of chemotherapy or radiation to kill cancer cells, such treatments also kill blood-producing stem cells in the patient's bone marrow. Damage to bone marrow stem cells lowers the white blood cell count, which makes the patient more likely to get serious, even fatal, infections. Bone marrow transplantation (BMT) or peripheral blood stem cell (PBSC) transplantation can be used to restore the patient's blood-producing stem cells to a healthy level after high-dose chemotherapy.

In these procedures, some of the patient's stem cells are removed before the chemotherapy begins. Stem cells can be taken from either the circulating (peripheral) blood or from the bone marrow. They are returned to the patient after chemotherapy. The stem cells soon re-establish themselves and restore the body's ability to produce blood cells.

Peripheral blood stem cell transplantation offers some advantages over bone marrow transplantation because PBSC can be used even when cancer cells have spread to the bone marrow. In most cases, the stem cells can be collected in an outpatient setting and the patient will not need general anesthesia.

Bone marrow or peripheral blood stem cell transplantation may be used as adjuvant therapy in some women with a high risk of recurrence, or for treatment of advanced disease. The effectiveness of this treatment is still being studied. At this time these procedures are best done as part of a clinical trial.

Immunotherapy

Trastuzumab (Herceptin) is a drug that attaches to a growth-promoting protein known as HER2/nue, which is present in small amounts on the surface of normal breast cells and most breast cancers. Some breast cancers have too much of this protein which can cause the cancer to grow and spread faster. Herceptin can stop the HER2/nue protein from causing breast cancer cell growth. It may also help the immune system to better attack the cancer.

Herceptin is generally started after standard hormonal or chemotherapy is no longer working, but studies are going on now to see if it should be added to the first course of chemotherapy. The side effects of this drug are fairly mild; they may include fever and chills, weakness, nausea, vomiting, cough, diarrhea, and headache.

Clinical Trials

Studies of promising new treatments are known as clinical trials. A clinical trial is done only when there is some reason to believe that the new treatment may be of value to the patient. Treatments used in clinical trials are often found to have real benefits. The main questions the researchers want to answer are:

• Does this treatment work?
• Does it work better than the one we're now using?
• What side effects does it cause?
• Do the benefits outweigh the risks?
• Which patients are most likely to find this treatment
• helpful?

During your course of treatment, your doctor may suggest that you look into a clinical trial. This does not mean that you are being asked to be a human guinea pig. A clinical trial is done only when there is some reason to believe that the treatment being studied may be of value. Nor does it mean that your case is hopeless and your doctor is suggesting a last-ditch effort.

Clinical trials are carried out in steps called phases. Each phase is designed to answer certain questions. Ask your doctor if there is a clinical trial that might be right for you. Then learn all you can about that trial. There can be risks as well as benefits. No one knows in advance whether the treatment will work better than standard treatments or exactly what side effects will occur. Taking part is up to you. Even after you have joined, you are free to leave the study at any time, for any reason.

You can get a list of current clinical trials by calling the National Cancer Institute at 1-800-4-CANCER or visiting the NCI clinical trials web site for patients at cancertrials.nci.nih.gov.

Some Questions To Ask Your Doctor

As you cope with cancer and cancer treatment, you need to have honest , open discussions with your doctor. You should feel free to ask any question that's on your mind, no matter how small it might seem. Here are some questions you might want to ask. Be sure and add your own.

• Would you please write down the exact type of cancer I have?
• May I have a copy of my pathology report?
• Has my cancer spread to lymph nodes or internal organs?
• What is the stage of my cancer? What does that mean in my case?
• What treatment choices do I have? What do you recommend? Why?
• What are the risks or side effects of different treatments?
• Will I be able to have children after my treatment?
• How long will each course of treatment last?
• Will I be out of work? For how long?
• Will I be able to drive myself home after treatment or will I need help?
• What are the chances of my cancer coming back with the treatment you suggest?
• What should I do to get ready for treatment?
• Should I follow a special diet?
• What kinds of breast reconstruction are possible in my case?
• Will I go through menopause as a result of my treatment?
• What are my chances of survival, based on my cancer as you see it?