1. I’ve heard that a breast cancer tumor can be “graded.” What does that mean?
2. I have stage 1 breast cancer with no lymph node involvement. However, my cancer is an intraductal carcinoma with squamous cell metaplasia. Can you help me figure out what this means?
3. What is the normal range for alkaline phosphatase in a blood test?
4. Could you explain the different stages of breast cancer? I keep getting asked what stage mine is. My tumor was 9mm with 1 of 29 nodes affected.
5. What is the purpose of a mammogram?
6. Is there a way to minimize the discomfort associated with getting a mammogram?
7. What is the best time of month to have a mammogram, to ensure accuracy?
8. My mammogram results stated that a density was found with relatively smooth margination, but some lobulation. What does lobulation mean in this context?
9. I’ve read that breast density is a risk factor for breast cancer. Is that true?
10. I’m 35 and never have had an occasional ‘poking’ feeling on my left upper breast. My doctor found a lump (physical exam) and asked for a biopsy. However, a mammogram and ultrasound were negative. How accurate are mammogram and ultrasound?
11. I just turned 38 and had my first screening mammogram showed architectural distortion of the right breast. I have been asked to go back for additional views. What does this mean?
12. Is it possible for an individual who has had very bad experiences with mammography (i.e. technicians who needed to retake films several times and say they didn’t get enough compression, etc.) to have an ultrasound done annually instead? I do have fibrocystic breasts; is that a reason for needing to do films over and over again at one visit?
13. I am 51 and a mammogram showed calcifications in my breast. I have another mammogram in six months. Shouldn’t a biopsy be taken of the calcification to either confirm or deny a cancerous condition?
14. What does a needle biopsy entail?
15. Is a stereotactic needle biopsy painful?
16. If a large lump is biopsied by fine needle, can you be sure that they retrieved the right cells?
17. How do the stereotactic needle biopsy and the core needle biopsy compare?
18. What is a mammotone?
19. What are the pros and cons of excisional biopsy versus needle or core biopsy?
20. I am about to undergo a breast lumpectomy and sentinel node biopsy. What is involved in a sentinel node biopsy?
21. I am 25 and had a Fine Needle Aspiration (FNA) for a 2 cm nodule against my chest wall. The FNA showed no malignancy. My doctor recommends an Ultrasound Directed Core Biopsy to ensure the cells tested were taken from the nodule. Why would an FNA be recommended only to have it confirmed with a Core Biopsy?
22. I am going to have a lump removed from my breast. I have heard that the results can take a week. Why does this pathology procedure take so long?
23. I am 38 and these are the results of my biopsy: Periductal and stromal fibrosis, and chronic active inflammation. Focal mild intraductal hyperplasia. 2cm. What exactly does this mean?
24. My wife’s doctor is recommending axillary lymph node dissection. I’ve read that this can cause lymphedema and that some say this procedure is performed too often. Any thoughts?
25. I have had a mastectomy and axillary lymph node removal with no signs of lymphedema. I am resuming an exercise program and wonder if using nautilus equipment could increase my lymphedema risk?
26. What is a tumor marker? Is this part of a follow up treatment?
27. Last week, I went for the yearly appointment and when the doctor did the breast exam, he pinched my nipple (hard). I was curious if this was routine and if so, what is it for?
28. After lumpectomy, chemo and radiation are completed, what is the follow up procedure? Are there any meaningful blood tests that would indicate cancer recurrence?
29. Where can I find more information about “Sestamibi breast scan”? From what I understand, it is still under research and not FDA approved yet.
30. How reliable is a negative breast scintigram? How does it work? Where can I get more info on this test?
31. I am 20, and my doctor found a lump in my breast on a routine wellness exam. He recommended an ultrasound, rather than a mammogram. Could you suggest rationale for the ultrasound versus mammogram?
32. My friend was diagnosed with type II breast cancer and had the lump removed. Her doctor told her that there was a new blood test researched at Anderson Hospital in Texas, which was a true test to see if there was cancer anywhere else, and eliminated the need to have the lymphs removed. What is this test?
33. I’ve just finished radiation treatments and now every little twinge scares me into thinking the cancer is coming back. I was never like this before. I seem to be more susceptible to coughs and colds since I had my cancer surgery. Every time I get a little swollen lymph node with a respiratory infection I start to panic that it is the cancer coming back (or spreading). Does this worry ever go away? I don’t want to be always fretting about my health. Is there any good way to tell when something is minor and not life threatening, besides running to the doctor? I feel very embarrassed when I do this.
34. My mother had breast cancer 10 years ago. It did not spread to any lymph nodes. Last week she had a large tumor removed from right ovary. Is it possible for breast cancer to show now, after 10 years, on ovaries? We do not know if lymph nodes were affected yet.
35. What does the size or kind of cancer have to do with its rate of spread to other sites?

Diagnosis

I’ve heard that a breast cancer tumor can be “graded.” What does that mean?

The grade of a tumor in the breast refers to how abnormal it looks under the microscope. Differentiated cells look like normal breast tissue cells. Tumors that have cells that are difficult to recognize as breast tissue are known as “poorly differentiated” or “undifferentiated.” Grade 3 means the cells of the tumor are poorly differentiated, that is, they have changed to a degree that it is difficult to figure out where they arose from as they do not appear as normal breast cells. A cancer’s nuclear grade is based on features of the central part of its cells, the nucleus. The higher grade cancers tend to spread more quickly.

Once you are diagnosed with breast cancer, the tumor is graded. If you have poorly differentiated tissue, you may be counseled to decide upon a partial or simple mastectomy to remove it. The next step is to determine if there has been spread of the disease to other parts of the body. The spread of the tumor to the rest of the body is checked by a series of tests usually during the initial assessment. The tests may include chest x-rays to detect spread to the lung or lining of the lung. X-rays and/or scans of the bones, liver, and skull. If more information is needed, CAT (computerized axial tomography) scans and MRI (magnetic resonance imaging) can be done. These tests are usually not done first because the patient is exposed to higher amounts of radiation and they are costly.

I have stage 1 breast cancer with no lymph node involvement. However, my cancer is an intraductal carcinoma with squamous cell metaplasia. Can you help me figure out what this means?

Stage I means the tumor measures 2 cm (about 1/4 inch or smaller in diameter). The cancer cells have not spread to the lymph nodes.

Intraductal means the cancer is contained within the duct of the breast.

Squamous cell metaplasia is merely explaining the cells within the affected area. Squamous cells are flat scale like epithelial cells. Epithelial cells are cells that normally line the ducts.

Metaplasia is one of the 4 phases of normal division of cells. Metaplasia is the arrangement of chromosomes in which they separate into exactly similar halves.

Let’s put this together: You have a small, seemingly noninvasive tumor in one the ducts of your breast (in the squamous cells of the lining of the duct in the metaplasia stage of cell division).

Keep in mind your physician is familiar with all aspects of you situation, medical history and your preferences. Communicate with your physician about the interpretation of your pathology report. Discuss the treatment alternatives which are determined by the size of the tumor, and other favorable or unfavorable features. These features include the biomarkers, estrogen receptors, Her-2 oncogenes and others. These features are identified from the tumor itself. Treatment does vary when all of these features are taken into consideration.

What is the normal range for alkaline phosphatase in a blood test?

The normal level of alkaline phosphatase is 1.5-4.0 using the Bodansky method of measurement. Other laboratories may use different methods of measuring blood values. Other methods of measuring alkaline phosphatase are higher for normal values. Therefore, your reading appears normal.

Could you explain the different stages of breast cancer? I keep getting asked what stage mine is. My tumor was 9mm with 1 of 29 nodes affected.

The stages of breast cancer are based on the TNM system. T refers to the size of the tumor, N refers to whether it has spread to the lymph nodes, and M refers to whether there are metastases in other parts of the body. This information is used to determine the stage numbers. Stage I is T1 (the tumor is small, less than 2cm with no lymph node involvement or the disease is confined to the breast). Stage II can have several different characteristics: a small tumor with positive lymph nodes; a tumor 2-5 cm with positive or negative lymph nodes; a tumor larger than 5 cm with negative lymph nodes. Stage III is a large tumor that has invaded the muscles of the chest wall, the overlying skin, or lymph nodes above the collarbone. Stage IV is when the cancer has spread to other parts of the body, typically the bones, liver, or lungs. These stages are altered according to new information that the surgeon and pathologist find.

Mammograms

What is the purpose of a mammogram?

A mammogram is a low dose x-ray study of the breasts. The purpose of a mammogram is to detect breast cancer early in its development. A mammogram will identify an area of breast cancer when it is very small, two years before it can be felt with physical examination. When cancer is developing at an early stage, it will have a better response to treatment and may require less treatment. At this time, it is the best method of screening. Mammograms are not routinely done before age 40, unless the woman has a strong family history (mother or sister who has had breast cancer) or symptoms of breast disease. The time to start mammograms in this case would be 10 years before her relative was diagnosed. For example, if your mother was diagnosed with breast cancer at age 40, you would start mammograms at age 30. Before the age of 40, the breasts are very dense, making it difficult to detect lumps.

If a woman has no symptoms, and no family history of breast cancer, The American Cancer Society recommends a mammogram once a year after 40 (a baseline mammogram should be performed at 40). In addition, it is recommended to have a clinical physical exam of the breast by a physician every year (an examination by hand) and a breast self-exam once a month.

Is there a way to minimize the discomfort associated with getting a mammogram?

The mammogram machine has compression plates to thin and flatten the breast. If the compression is adequate, the quality of the picture is improved and the x-ray dose is lower. Two or three views are taken of each breast to unfold the overlapping breast densities seen on the film. Some women’s breasts are unusually sensitive to the squeezing necessary to pull the breast tissue away from the chest wall and compress it between the plates for the x-ray pictures. The procedure is short and takes only a few seconds for each exposure. It may help to lessen the discomfort of the procedure by delaying the test until after a menstrual period or early in the monthly cycle. Every person’s ability to tolerate pain or discomfort varies. Most women admit that any pain associated with mammography is short and the benefits far outweigh the momentary discomfort. Mammography is a means for detecting breast cancer in an early stage. Detecting breast cancer early contributes to a higher survival rate and a reduction in mortality.

Research is being done in imaging technology such as magnetic resonance imaging, digital mammography, scintigraphy, and positron emission tomography. The National Cancer Institute scientists are researching methods to detect traces of breast cancer in blood, urine and nipple aspirates. Until another tool proves to be as effective or more effective, continue with your annual mammography.

What is the best time of month to have a mammogram, to ensure accuracy?

Many women like to schedule their mammogram a week or two after a period, but comfort is the only reason. Some women’s breasts are very sensitive premenstrually due to the hormone activity. The accuracy of the mammogram should be the same before and after your period.

My mammogram results stated that a density was found with relatively smooth margination, but some lobulation. What does lobulation mean in this context?

Lobulation refers to a more or less well defined portion of the breast gland called a lobule. Your lobules have a higher level of definition, or lobulation. Lobulation does not seem to indicate cancer.

I’ve read that breast density is a risk factor for breast cancer. Is that true?

The breasts naturally become less dense as we age. So, breast density is a risk factor in older women.

I’m 35 and never have had an occasional ‘poking’ feeling on my left upper breast. My doctor found a lump (physical exam) and asked for a biopsy. However, a mammogram and ultrasound were negative. How accurate are mammogram and ultrasound?

Breasts of women in their 20’s are mostly made up of breast tissue, making them very dense. This breast tissue decreases in women in their 30’s to about one-half, the other half is fat. A lump in the middle of dense breast tissue often won’t show up on the mammogram because the tissue hides it. If the lump is in the fat tissue, it is more obvious on the mammogram. The chance that a mammogram will not show a lump in women in their 30’s is 9-20%. So, mammograms are not 100% accurate.

Ultrasound is often used to gather more information about a lesion that is found on a mammogram. It can tell the doctor if the lesion is a cyst or a solid lump. It can show a distinct lesion with edges or mixed areas with no definite lump. The problem with the ultrasound when the mammogram does not show the lesion is that the technician cannot ultrasound the whole breast accurately. In a young breast like yours, the breast has many changes in contour and density. This makes it difficult to tell the difference between breast tissue and a lesion.

There are conditions of the breast that are not cancer but there is no way to tell what it is unless a biopsy is done. Your physician is appropriate in asking for a biopsy. I encourage you to follow through with the recommendations of the physician to have a biopsy to find out what the lump is exactly.

I just turned 38 and had my first screening mammogram showed architectural distortion of the right breast. I have been asked to go back for additional views. What does this mean?

Mammograms look at the breast and take pictures of the soft tissue. Architectural distortion is a term the radiologist used to describe the breast tissue in the right breast behind the areola that may have an abnormal area of density. The dense areas which are breast tissue, and are normal for your age, appear as shadows or show up white on the mammogram. As a woman grows older the fat tissue becomes more prevalent in the breasts and shows up gray on the mammogram. Lumps are the same density as breast tissue and both show up as white areas. In your case, when a very dense area looks suspicious, it is necessary to examine the dense area more closely with different views of the breast so it is clearer as to what it is. This is the normal procedure. I congratulate you for getting your first mammogram at age 38 and encourage you to follow through with breast screening the rest of your healthy life.

Is it possible for an individual who has had very bad experiences with mammography (i.e. technicians who needed to retake films several times and say they didn’t get enough compression, etc.) to have an ultrasound done annually instead? I do have fibrocystic breasts; is that a reason for needing to do films over and over again at one visit?

Your age may be one factor in the efficacy of the mammogram. If you are under the age of 50, your breasts may be much denser with breast tissue which makes it more difficult to study and see any problems. After the age of 50, the breast has more fatty tissue and cancer shows up against fat tissue. If it is necessary to do extra films at the time of your mammogram, it is an attempt to provide the best studies possible.

Women who have fibrocystic disease have breast tenderness and report that having the mammogram causes discomfort and sometimes extreme pain with the compression of the breast. It is important that a trained, experienced technician conduct the mammogram in a sensitive, caring manner. In cases where women experience great discomfort they should discuss this with their technicians and physicians. The process should have tolerable discomfort.

An ultrasound sends high frequency sound waves through the breast. The sound wave bounces back if something like a tumor is in the way. If nothing is there, the wave goes straight through the breast tissue. An ultrasound does not pick out small details like a mammogram but does show characteristics of an existing lump. It is mostly used to get more information about an existing lump, such as, whether it is a fluid filled sac or if it is a solid tumor. The problem of using ultrasound instead of a mammogram is that with ultrasound the entire breast cannot be done accurately. Because of the density and contour of the breast, it is too difficult to tell normal breast tissue from a tumor. Ultrasound is best for looking at an existing lump for precise characteristics.

I am 51 and a mammogram showed calcifications in my breast. I have another mammogram in six months. Shouldn’t a biopsy be taken of the calcification to either confirm or deny a cancerous condition?

Your question is very important because so many women are alarmed about waiting six months for another mammogram and a final diagnosis. It is not unusual for a radiologist to recommend a repeat mammogram in six months when the calcifications are new and just a few in one area. If the calcifications are precancer, there will be more of them in six months and possibly a change in the size and shape. A biopsy is necessary at this time. If there is no change after six months, the calcifications may be benign (noncancerous). Over 80% of calcifications are benign which do not require biopsies.

If it turns out that the calcifications are precancer, waiting six months usually does not make a difference because it would take several years for it to develop into cancer. Some women simply will not wait six months and request a biopsy. For your peace of mind, you may want to get a second opinion.

Biopsies

What does a needle biopsy entail?

A fine needle biopsy is used to determine whether a lump/mass that can be felt is a cyst or a tumor. A needle is inserted into the lump or mass and using suction, fluid and cells are drawn in the syringe. The material is squirted onto a slide, which is examined under a microscope by a cytologist. There is no tissue to look at, so the cytologist must be a specialist at looking at cells rather than tissue.

Fine needle biopsy can also be done on lesions that are detected on a mammogram but cannot be felt. This is called stereotactic needle biopsy. The patient lies face down on a special table that allows her breasts to hang down. A computer can determine where the lesion is. A needle quickly shoots into the lesion and removes a few cells from different areas of the lesion so it is well sampled. Then the samples are studied by a cytologist.

A core needle or wide needle biopsy is done the same way as a fine needle biopsy except a larger needle is used. This procedure requires some Lidocaine or other local anesthesia. A small portion of the tumor is removed using a corkscrew-like needle. The patient feels pressure but no real pain. The core biopsy removes a piece of tissue rather than just cells which makes it easier for a pathologist to read.

Is a stereotactic needle biopsy painful?

The procedure should not be painful. Local anesthesia can be used, but it is not needed for most women and could be more painful than the localization of the needle biopsy. You should only feel the needle going into the skin. Pre-medication such as a pain pill is not recommended as you need to be fully cooperative for the procedure. The procedure should be explained to you, which helps to reduce your anxiety about the procedure.

If a large lump is biopsied by fine needle, can you be sure that they retrieved the right cells?

A fine needle biopsy usually removes cells from the lesion at several passes for a good sample. Since your lesion is large, a larger biopsy may be indicated to be certain there are no cancer cells present. The whole lesion certainly could be benign (nonmalignant). Even if the lump is not malignant, you may not want this in your breast and can have it removed.

How do the stereotactic needle biopsy and the core needle biopsy compare?

A stereotactic core biopsy is an aspiration of cellular material from a breast lesion for cytologic examination to determine if the lesion is malignant or not. The needle used in core biopsies is larger than the needle used in a fine needle aspiration biopsy (FNAB). It removes a cylinder of tissue about 1/8 inch in diameter and 1/2 inch long from the abnormality. If the doctor uses ultrasound to guide the needle, the procedure is a stereotactic needle biopsy. Computers show the exact position of the lesion using mammograms taken from two angles. Then, a computer guides the needle to the correct area. This type of biopsy can be done in most breast abnormalities detected through mammograms or ultrasound. It is preferred over a surgical biopsy, when possible, because it gives the doctor the information needed. If cancer is present and surgery is needed, then there is only one surgery involved. There are some limitations in its use. The procedure is designed to eliminate the possibility of free cells circulating. Suction is stopped before withdrawal of the syringe so that all the cells are inside the needle. There are different types of biopsies: FNAB, incisional and excisional. All types of biopsies reveal whether a cancer is present. The physician chooses the correct type of biopsy according to each patient’s situation. There are new techniques being developed, which may allow the surgeon to do an entire lumpectomy with a larger needle. However, the procedure must get clean margins which only the open surgical excisional biopsy does at present.

What is a mammotone?

Cancer is often associated with some very fine specks of calcium, called microcalcifications. Eighty percent of microcalcifications are not cancer but sometimes do indicate cancer or precancer. Mammotones are a type of biopsy that suctions out tissue of the breast. The amount of tissue that a mammotone pulls out is better at finding microcalcifications than other procedures, such as a core biopsy. Using the mammotone needle requires only a single insertion, as it has a vacuum that pulls out specimens from multiple areas of the lesion. A mammotone biopsy is more reliable than manual core biopsy for early cancer detection. Another advantage is that there is minimal discomfort for the patient. Therefore, it is a procedure that does diagnose precancer and cancer in lumps and determines whether or not microcalcifications are cancer.

What are the pros and cons of excisional biopsy versus needle or core biopsy?

The biopsies you mention are 3 different procedures and it is important that you understand the differences between each one, which one is best for you and why. The excisional biopsy is the removal of the entire lesion with some marginal tissue, but it is an open surgery requiring more time and some anesthesia. The fine needle biopsy and the tru-cut (core) biopsy are used to sample the cells or tissue to determine what the lesion is through the least invasive procedure. There is usually no scar or dent in the breast tissue from these two procedures. If it did turn out to be cancer, then options for treatment can be discussed and definitive surgery could be done at a later date. The advantage of the tru-cut, or core, is that a piece of the lump (usually the center) is removed, rather than just cells, as when a needle biopsy is done. The core biopsy is easier for the pathologist to read. The advantage of the needle biopsy is that the needle is passed through different areas of the lump to make sure all of it is sampled. Some surgeons have a bias toward one or the other.

It is best to follow your surgeon’s advice and accept the procedure in which he/she has the most experience. Core biopsies are done in parts of the country where advanced cytology studies are unavailable. A pathologist can diagnose the cells in a core biopsy. The needle and core biopsy are as accurate as an open biopsy with the excisional biopsy. They are not as invasive and need only some Lidocaine to numb the area. The procedures cost one-third as much as the excisional, you have no scar and practically no recovery time, and you have an answer within 36 hours or less. If the core or needle biopsy does not give the surgeon the information that is needed, then an open biopsy is indicated.

I am about to undergo a breast lumpectomy and sentinel node biopsy. What is involved in a sentinel node biopsy?

When a cancer lesion is in the breast, the lymphatic vessels will drain from that region containing the cancer to an initial node called the sentinel node. It is the first lymph node that would be positive if the cancer is spreading. With a sentinel lymph node biopsy, a radioactive tracer or a blue dye is injected into the region of the tumor. The dye or radioactivity is carried by the lymphatic vessels to a sentinel node. If the cancer has metastasized (spread), this is the lymph node most likely to contain a metastasis.

At the time of the initial surgery when the lump is dissected, the surgeon will remove the sentinel node to be examined under the microscope at the laboratory. If the sentinel node has cancer cells, the surgeon will remove more lymph nodes for examination. If the sentinel node is negative or free of cancer, the extended lymph node surgery can be avoided. The advantage of this new procedure is that it will reduce the number of women having axillary dissection, which is the standard procedure of most breast cancer patients. The axillary dissection does have significant side effects such as lymphedema or swelling of the arm.

As preoperative preparation, you should receive information explaining the surgical procedure, the usual post-operative course and possible side effects of surgical interventions (swelling, pain, infection, etc.).

I am 25 and had a Fine Needle Aspiration (FNA) for a 2 cm nodule against my chest wall. The FNA showed no malignancy. My doctor recommends an Ultrasound Directed Core Biopsy to ensure the cells tested were taken from the nodule. Why would an FNA be recommended only to have it confirmed with a Core Biopsy?

The FNA biopsy contained only cells to be interpreted under a microscope as to whether malignant cells were present. Since there was no tissue to look at, it required an experienced cytologist who can look at cells out of context. The FNA biopsy may not have given complete and clear information. When this happens, a larger biopsy is necessary. The next step is to do a core biopsy. The core biopsy uses a larger needle to enter the lump or nodule and remove a core of tissue. The advantage of the core biopsy is that a small amount of tissue is removed, rather than just cells. It is easier for the pathologist to read for accuracy. For some women, the needle biopsy is all that is needed as long as the mammogram, ultrasound, clinical exam and pathology report all agree. This was not the case for you. It was most important that the nodule be thoroughly sampled.

I am going to have a lump removed from my breast. I have heard that the results can take a week. Why does this pathology procedure take so long?

The reliable procedure of analyzing the biopsy tissue consists of several steps. The preparation of the slides which contains many stained sections of the tissue takes about 24-36 hours. After a pathologist receives the slides, he needs a day or two to analyze and make a diagnosis. A written report is sent back to the surgeon within a week. Some doctors call the pathologist within a couple of days to let their patients know what is happening since waiting is frightening for most women. But it is not unusual for a doctor to have the patient wait a week for the written report, so a detailed explanation can be made in the doctor’s office and an opportunity for discussion of follow-up.

I am 38 and these are the results of my biopsy: Periductal and stromal fibrosis, and chronic active inflammation. Focal mild intraductal hyperplasia. 2cm. What exactly does this mean?

I will define some of the terms included in your biopsy which may help you understand better. Stroma means the supporting tissue that makes the framework of an organ, in this case the duct of the breast. Fibrosis means the formation of fibrous tissue (composed of fibers) in the stroma. Hyperplasia means the increase in the number of normal cells in normal arrangement in a tissue. It can be the result of inflammation. These terms indicate non-malignant changes in breast tissue. You should ask your physician for the interpretation of your biopsy. Any changes in breast tissue require careful monitoring on a regular schedule of check-ups, which include physician breast exams and mammograms.

Lymph Node Removal/Radiation

My wife’s doctor is recommending axillary lymph node dissection. I’ve read that this can cause lymphedema and that some say this procedure is performed too often. Any thoughts?

Removing lymph nodes is a marker of prognosis, and is done to determine if there are any microscopic cancer cells. It helps the physician decide about future therapy. I know there is different thinking about the status of lymph node removal. Dr. Love, a physician who has written a book about breast cancer states there is no evidence that axillary surgery affects survival but she feels it is an important operation. Lymphedema is a risk when nodes are removed. Surgeons who do perform dissection generally limit it to Level I which minimizes the risk of lymphedema. A Level I dissection limited to the nodes inferior to the intercostobrachial nerve has been suggested. There are different types of cancer that determine different ways to treat and monitor the cancer. I encourage you to be candid with your wife’s surgeon about your concerns and seek other opinions and resources.

I have had a mastectomy and axillary lymph node removal with no signs of lymphedema. I am resuming an exercise program and wonder if using nautilus equipment could increase my lymphedema risk?

I commend you for exercising as it is a very important part of your well being. It is extremely important that you know the type of exercise you can do safely without promoting swelling due to compromised movement of lymph fluid through the lymphatic system. First, always wear a compression sleeve while exercising, flying in an airplane or when in high altitudes. You should avoid any exercises that put strain on your arm and shoulder. Some of the machines may be contraindicated. Call your surgeon about what machines you need to avoid. There is a diagnostic procedure called lympoangioscintigraphy that visualizes your lymphatic system to determine if you have normal drainage capacity. If you do have normal drainage, you may not have any restrictions.

I want to refer you to the National Lymphedema Network, Inc.for more information about how to avoid developing lymphedema. Their hotline is 1-800-541-3259.

Other Tests

What is a tumor marker? Is this part of a follow up treatment?

A tumor marker is a biochemical substance that identifies or indicates a specific tumor. Antigens on the surface of breast tumor cells can serve as markers for diagnosis, assessing for prognosis and monitoring for recurrence. Tumor markers can be a part of follow up treatment in order to follow response to treatment.

Last week, I went for the yearly appointment and when the doctor did the breast exam, he pinched my nipple (hard). I was curious if this was routine and if so, what is it for?

Squeezing the nipple with a breast examination is done to see of there is any discharge. All the ducts of the breast join together under the nipple to flow out the nipple. There can be normal discharge with squeezing the nipple which would appear clear or cloudy. An abnormal color is red-brown or red, suggesting that it contains blood. This type of discharge needs further examination to see if cancer cells are present. Most nipple discharge or secretions are not cancer.

After lumpectomy, chemo and radiation are completed, what is the follow up procedure? Are there any meaningful blood tests that would indicate cancer recurrence?

In the past, long term follow-up of breast cancer was routine bone scans, often CAT scans at 6-12 month intervals. Recent studies are showing that very many breast cancer recurrences are detected between routine scans indicating this approach of yearly scans may not be beneficial. Now, many physicians are recommending the use of the serum tumor test CA-27.29. This blood test has been approved by FDA for the screening of breast cancer recurrence. Those who have an elevated CA-27.29 then have further testing in search of metastasis (recurring cancer in the breast or other part of the body). There is no proof yet that this blood test has long term benefits for those individuals undergoing screening. In addition, however, there is no controversy that all breast cancer survivors need to continue with yearly mammograms and clinical exams by their physician. If any symptoms occur such as loss of weight, bone pain, enlarged lymph nodes, etc., these symptoms need to be reported to the physician and have a diagnostic work-up.

Where can I find more information about “Sestamibi breast scan”? From what I understand, it is still under research and not FDA approved yet.

Technetium-99m Sestamibi is being studied for the following: to determine if benign lesions can be distinguished from malignant lesions adequately, to determine if lesions less than 1.2 cm can be identified, and to determine how much cellular uptake occurs. The uptake is related to the vascularity (composed of blood vessels) and new vascularity. Speak to your oncologist or primary physician about your inquiry and to determine where you could have scintigraphy scan of your breast done.

How reliable is a negative breast scintigram? How does it work? Where can I get more info on this test?

Scintigraphy has been the use of isotope screening for skeletal metastases of breast cancer. Thallium-201 has been used and Technetium-99m Sestambibi may still be under investigation to identify breast lesions. It was unclear with Sestambibi if benign lesions could be distinguished from malignant lesions adequately to eliminate some of the procedures needed to diagnose cancer. The size of the lesion detection has been a factor, in that it may not identify lesions less than 1.2 cm. The uptake of the isotope is related to how vascular the area is (more blood vessels in the area, more uptake). Recent studies of scintigrams to screen for bone metastases show that scintigraphy may be of value in symptomatic or more advanced breast disease but show minimal detection rate in women who were node negative and those who have tumors less than 2 cm. It is recommended, based on studies, that routine bone scans not be adopted for follow-up of patients with stage II (tumors 2 cm or less) breast cancer. Bone scintigraphy should be reserved for evaluation of patients presenting with symptoms suggestive of bone metastases. Many physicians recommend the use of a serum tumor test, CA-27.29, which has been FDA approved for the screening of breast cancer recurrence instead of bone scans. If the blood test CA-27.29 is elevated, the individual should undergo further testing to search for metastasis.

I am 20, and my doctor found a lump in my breast on a routine wellness exam. He recommended an ultrasound, rather than a mammogram. Could you suggest rationale for the ultrasound versus mammogram?

An ultrasound is the use of high frequency sound waves that are sent through the breast to detect a lump or obtain information about a lump already found in the breast tissue. There is no radiation used with this diagnostic procedure. It is used mostly to investigate a known lump. For example, this technique can help determine whether the lump is filled with fluid, like a cyst, or if it is solid, like a fibroadenoma or a cancerous lump. If it is a cyst, the sound waves of the ultrasound go through it. If it is solid, the sound waves bounce back. The best use of ultrasonography (ultrasound) is to explore a lump or an area which has been already found by physical examination or mammography.

My friend was diagnosed with type II breast cancer and had the lump removed. Her doctor told her that there was a new blood test researched at Anderson Hospital in Texas, which was a true test to see if there was cancer anywhere else, and eliminated the need to have the lymphs removed. What is this test?

The Food and Drug Administration approved the breast tumor marker test for general use. It is a simple, cost-effective blood test to detect breast cancer recurrence months earlier than any other method. The blood test measures a substance produced by the mucin gene. Levels two or more times higher than the normal mucin gene product is an indication that there is a recurrence of breast cancer. The studies done at Anderson Hospital and four other institutions have shown a correlation of elevated mucin gene and recurrence of breast cancer in almost every case. About 40% of newly diagnosed breast cancer this year will have Stage 2 or Stage 3 disease. After treatment of surgery combined with chemotherapy and/or radiation, these women are still at high risk of recurrence of breast cancer. This blood test will be able to detect very early recurrence requiring further treatment. However, this test does not eliminate the need for lymph node biopsy. Lymph node biopsy is needed at the time of biopsy to stage the disease and help the physician direct the treatment needed.

Recurrence and Spread

I’ve just finished radiation treatments and now every little twinge scares me into thinking the cancer is coming back. I was never like this before. I seem to be more susceptible to coughs and colds since I had my cancer surgery. Every time I get a little swollen lymph node with a respiratory infection I start to panic that it is the cancer coming back (or spreading). Does this worry ever go away? I don’t want to be always fretting about my health. Is there any good way to tell when something is minor and not life threatening, besides running to the doctor? I feel very embarrassed when I do this.

Women who have completed treatment and are survivors of breast cancer do live with an ongoing fear of recurrence. It is one of the most common concerns of survivors. This fear does subside with increased survival time. For coping with the fear of recurrence, therapists suggest you confront the fear and examine your feelings and attitudes about it. You have done this by expressing yourself and identifying your behaviors and fears. This is the first step in resolving your fears and building positive attitudes. The therapists recommend a program of exercise, relaxation, reading and mental imagery.

Exercise programs that involve aerobic exercise and regular walking play a positive role in physical and psychological health. You may start your exercise program with a self paced program of walking 4-5 times per week for 20-45 minutes in your neighborhood. This will improve your physical performance and lessen fatigue. You don’t mention fatigue but physical well-being contributes to mental well-being.

There are studies that show that cancer survivors with close family ties and support networks can reduce the difficulties of adjustment and fears of cancer recurrence that you are experiencing. Joining a support group designed specifically for women with breast cancer will be a great boost for your adaptation to post treatment. The survivors in support groups will be helpful in providing support and offering suggestions for effective coping behaviors for your fear of recurrence. You will find other women have had the same feelings and behaviors that you are experiencing. You will identify with some suggestions and adopt some of the behaviors that will help you cope with or overcome your fears.

Research has shown that support groups may be the most powerful influence on adaptation in any phase of breast cancer from diagnosis through post treatment. The results show an increased sense of self power as a result of increased coping skills. The wisdom that survivors have to share is invaluable. Call your local American Cancer Society for the names of support groups that are available in your community. Examples are: I Can Cope, Y-ME National Breast Cancer Organization (800 222-2141), Wellness Community Support Group, Encore Program (YWCA), and the National Cancer Institute (800 4-Cancer).

I want to emphasize that the feelings and fears you have described are experiences the great majority of cancer survivors have. If you have not shared these fears with your physician and oncology nurse, please do so. They can review with you the symptoms that need to be reported. The oncology nurse is well educated about physical and emotional changes that women experience. Ask for information on support groups and names of other patients with similar problems you can talk to. Monthly self examination is an important method of detecting a recurrence. The doctor will outline the frequency of physical examinations and mammograms to detect any recurrence. This medical follow-up is necessary for the rest of your life. You are facing a difficult challenge, but you can overcome your fears with more knowledge and help from others. The public library is also a good source of books on breast cancer that deal with your specific problem.

My mother had breast cancer 10 years ago. It did not spread to any lymph nodes. Last week she had a large tumor removed from right ovary. Is it possible for breast cancer to show now, after 10 years, on ovaries? We do not know if lymph nodes were affected yet.

The current belief is that breast cancer is a chronic disease like diabetes or high blood pressure that a woman will always have in her life. It is usually a slow growing cancer and can spread to another part of the body and not be detected for 10 or 20 years. Some women have recurrence earlier than 10 years. It is possible that women who have had breast cancer can be at a higher risk for developing another primary type of cancer in later years. The physician can tell you if the present cancer is a recurrence of the breast cancer or a new primary type of cancer. The oncology physician will determine the type of treatment (chemotherapy, radiation) based on the type of tumor, the stage and size of the tumor, the location, and possibly your mother’s health status. Chemotherapy and all types of cancer treatment have changed and improved over the last 10 years. Feel comfortable asking the doctor what particular treatment is being planned for your mother. Ask if it is a certain protocol based on scientific research, the names of the drugs, length of time the treatment is expected to last and the possible side effects. Have confidence that the physician will treat her with the latest protocols and take steps to see that she will have the best care.

What does the size or kind of cancer have to do with its rate of spread to other sites?

A biopsy of the breast tissue is done to see if cancer is present and, if so, what kind of cancer it is. First, it is determined whether the cancer is invasive (infiltrated) or intraductal (in situ). In situ cancer does not metastasize (spread) and can be cured with surgery. If it is invasive, the pathologist does studies of the cells to determine the exact type and how aggressive it is. The cancer can be classified by noting the characteristics of the cells and growth patterns. Cells that are poorly differentiated, meaning not clearly defined or looking very abnormal, are usually more aggressive. Well differentiated cells, looking closer to normal, are less aggressive. The most aggressive cancer has a lot of cells rapidly dividing. The well- or moderately-differentiated cells have few dividing cells. The rate of dividing cells or the growth rates are measured by flow cytometry to determine the amount of DNA in a cell. Tumors with high rates of DNA have less favorable outcomes because they are fast-growing. Tumors that have the normal amount of DNA are less aggressive. If there are a lot of cancer cells in the blood vessels or lymph vessels at the site of the tumor, the tumor is more aggressive. The pathologist may also study enzymes the breast cancer secretes. The presence of the enzyme Caphepsin D in high levels can attack surrounding tissues and help the cancer spread into the blood vessels. These are examples of information that is analyzed to predict which cancers are more aggressive, or how fast the cancer is likely to spread to other organs. This information also helps to determine the correct treatment to kill the cancer and prevent recurrence.

For more information:

Go to the Breast Cancer health topic.