BCネットワークは,アメリカ認定の非営利団体です。 日米両国に在住の日本人女性達に乳がんに関する最新の情報 、乳がん治療後の生活の取り組み、乳がん早期発見、 啓発情報発信を押し進めていく非営利団体です。 Knowledge is power.  正しい知識は患者自身の力、支えになると信じて活動しています 。

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“The Future Looks Bright”
A Conversation with Dr. Freya Schnabel, Director of Breast Surgery

A publication for the NYU Langone Medical Center Community September/October 2010

LinkIcon"The Future Looks Bright"


Physician-Patient Communication: An Opportunity for Improvement in the Lives of Women with Breast Cancer


By Freya Schnabel, MD
(Director of Breast Surgery NYU Langone Medical Center)

(This speech was presented by Dr. Schnabel at The Second Japanese Breast Cancer Symposium @ Yokohama, Japan 7/10/2010)


Perspectives: History of science, history of patients’ rights, increasingly complex treatments, clinical trials, patient advocacy

1.Historical Perspective


First, I would like to thank Makiko Yamamoto of the Young Japanese Breast Cancer Network organization and all the organizers of this conference for the opportunity to be with you today. And I’d like to thank all the participants in this conference for coming here today and showing their commitment to the cause of improving the lives of women with breast cancer in Japan and throughout the world. Usually, when I give a lecture about breast cancer, I rely on scientific evidence to make my arguments. I show many slides with tables and graphs, and I discuss the data represented using statistical terms. But today, I am here to talk about a topic that is extremely important to the lives of women with breast cancer, yet cannot be discussed in scientific and statistical terms. I have been asked to discuss physician-patient communication and breast cancer advocacy.

In the time before modern diagnostic and treatment methods, it was not terribly important for individuals to understand the nature of their illnesses. In fact, many times, the practitioner who treated them had little understanding of the science of normal human biology and pathophysiology. With increasing knowledge about the underlying causes of diseases, there was increasing opportunity for physicians to educate their patients, particularly when preventable causes for diseases could be identified. The earliest examples of this have to do with infectious diseases and epidemics. When the causes for cholera and yellow fever were identified, informing the public was critically important in order to prevent spread of these diseases. It is possible that these public health measures, undertaken to prevent the spread of epidemics, are the first example of the medical profession recognizing the critical importance of informing the public and eliciting the participation of non-professionals in changing outcomes.

Since that time, we have uncovered many other examples of diseases that can clearly be prevented or modified based on the participation of the patient. Some common examples are diabetes and heart disease, where diet and exercise (requiring patient commitment and participation) are so important to improve the outcomes of the diseases. In order for patients to comply with the recommendations for diet and exercise, etc. it is obvious that they need to be informed and educated by their physicians and other medical providers regarding the benefits of lifestyle modifications. This requires dialogue between physicians and patients, a giving and taking of information.

So, one general benefit of physician-patient communication is helping patients understand how to change their lifestyles to prevent or modify their chances of developing a disease.


2. Patients’ Rights perspective 

Our societies have placed increasing emphasis on the rights of individuals. Modern societies have taken great pains to describe the rights of individuals to be autonomous and self-determining. This has led to significant emphasis in the US on patients’ rights. Every hospital has to prominently display a “Patient’s Bill of Rights” enumerating a variety of rights every patient should expect to receive while being treated. These rights include the right to know who is treating them and the details of the proposed treatment.
We are required to obtain “informed consent” for all invasive procedures. Informed consent is a conversation where the patient is informed as to the reasons for the proposed procedure, along with the risks, benefits and alternatives of treatment.

In order for a patient to give genuine informed consent, the patient must understand the illness for which she is being treated, along with the details of the treatment and the possible outcomes. Without this understanding, there is no informed consent. This is certainly a legal issue, and in the US, health care providers can be sued for malpractice for performing procedures without the patient’s consent. It is also an ethical and moral issue.

Sometimes, the lines that appear so clear cut may be a bit blurry. Occasionally, a family will request that an elderly individual not be informed as to the details of a diagnosis, especially a malignant or life-threatening one, in order to spare their feelings and avoid any possible emotional consequences of receiving bad news. This “Don’t Tell Mama” syndrome is more common in certain ethnic and religious communities.
When I was new in medical practice, I felt strongly that withholding information from any patient was entirely wrong. At this point, I can admit that there are situations where it may be reasonable to modify how much information is shared with certain patients, and I am willing to let the patient (not the family) dictate how much information they are capable of hearing without being overwhelmed.

However, I always remind families that even if they think the patient does not know that they are sick, or doing poorly, people usually know. And it may be extremely stressful for everyone concerned to keep these toxic secrets. At this point, a patient who is not fully informed about her illness cannot give informed consent to any treatment or procedure. Being poorly informed takes away an individual’s rights to make decisions on their own behalf. And being kept in the dark about an illness may add unnecessary stress to a patient’s experience of her illness. Without complete information, a patient may feel a loss of control, a loss of empowerment, because she feels she is somewhat in the dark and lacks important facts that others (including her doctors) possess. So, appropriate physician-patient communication helps preserve an individual’s rights for self determination, allows the patient to fully consent to treatments and takes away the stress that comes with feeling a loss of power and control.

The treatments we offer patients with breast cancer have become increasingly complex, and involve multiple different modalities, including surgery, radiation therapy and an expanding variety of medical treatments, including chemotherapy, hormonal therapy and targeted therapies such as Herceptin. With this level of complexity, it is imperative to have an open discussion between physician and patient that reviews the details of the various treatments and their risks and benefits. Multiple studies have demonstrated that patients who understand their treatments are able to better comply with the treatment regimens. In my observation, patients who are well informed about their treatments are also better able to manage the side effects. Understanding why a treatment is being prescribed, and the benefit that it is expected to bring, helps a patient understand the importance of adhering to the regimen.

The best example of information and education ensuring compliance is the clinical trial. We all know that clinical trials are vitally important and have advanced our breast cancer treatments immeasurably in the last several decades. In order for a patient to enroll in a clinical trial, she must be informed about the trial in great detail, including the benefits and risks of the treatment. Only then can she give consent and be included in the trial.
If this concept of patient education and information is critical to consent to a clinical trial, it must be equally important for patients who are consenting to conventional treatment. Once again, we can see how open communication between physicians and patients leads to better outcomes, both in exploring new treatments and in adhering to all treatments, both new and established.

Last, but not least, the concept of patient advocacy has made an enormous contribution to the evolution of the doctor-patient relationship in the US, and I hope, in Japan. Patient advocacy groups in America helped disseminate information about breast conserving surgery – perhaps even before some in the medical community were ready to believe the data and embrace this new approach. Advocacy groups such as Susan G. Komen for the Cure have helped secure increased US governmental funding for breast cancer research over the past 20 years. These groups have raised consciousness about the importance of breast cancer screening in America, and have made concerted efforts to expand access to mammography for all women. The contributions of these advocacy groups are beyond measure.

The advocacy groups have emphasized the importance of patient input into medical decision making, and have been responsible in the US for the requirement of patient advocates in the review process for clinical trials. The perspective of the patient is thereby incorporated into trial design and monitoring of outcomes. Advocacy groups have insisted that patient voices be heard and helped us remember that we must never treat the disease while neglecting the interests of the person who has the disease. Advocacy groups represent the epitome of physician-patient partnership – the idea that when both physicians are fully engaged in the process, we can have our outcomes.
Clearly, physicians and scientists and women all over the world, when they work together, have the best opportunity to defeat breast cancer and remove the threat of this disease from the lives of women of future generations.

I am delighted to be here today and emphasize that as a practicing breast surgeon, I encourage my patients to participate fully in their care. I feel obligated to inform them fully regarding the options of treatment open to them, and I expect them to ask questions and discuss the topic with me until they are able to make decisions that are right for them. I see better compliance in patients who are informed and engaged in their treatment.
And I recognize the role that advocacy groups have played in furthering the search for a cure for breast cancer. I encourage all of you here today to continue to involve yourselves in the struggle against breast cancer, and I applaud the work of the Young Breast Cancer Network.

Thank you for your attention today, and I look forward to the panel discussion.

Understanding ductal carcinoma in situ

Harvard women’s Health Watch
Vol 16/number 2 October 2008
Most women diagnosed with this noninvasive breast cancer are alive 10 years later, and better treatments are emerging.

For the 62,000 women who will be diagnosed with ductal carcinoma in situ (DCIS) this year, the good news is far more important than the bad. While cancer is never a picnic, DCIS is the earliest detectable form of the disease. Some news that sounds "bad" — for instance, that the incidence of DCIS is increasing faster than that of any other type of breast cancer — is encouraging news. It means that more breast cancers are being detected early, while they can be nipped in the bud. Today, with standard treatment, 10-year survival rates for DCIS are approaching 100%, and the treatment is usually not too difficult to tolerate.

What is DCIS?
The name says a lot about the disease. "Ductal" refers to the site of origin, the tiny ducts that form a network connecting the milk-producing structures called lobules. "Carcinoma" indicates a tumor arising in the epithelium, or lining, of the ducts. "In situ" delivers the good news that the tumor is confined to its place of origin; it hasn't invaded the surrounding tissue or metastasized to other body tissues.

The diagnosis of DCIS describes a cluster of cells captured in the process of evolving from normal tissue to breast cancer. The journey is thought to begin with a series of genetic changes in breast cells. At first, these changes stimulate cell growth, resulting in ductal hyperplasia (an overabundance of normal cells), which may begin to fill the duct. Then the cells become distorted and look abnormal under a microscope. At this second stage of change, called atypical ductal hyperplasia, the cells' capacity for growth is further increased. DCIS proper is a third step in the process, in which a cluster of abnormal cells has filled the duct but hasn't broken through its walls. If it does breach the walls, it's called invasive breast cancer.

Carcinogenesis, the process by which cancer arises, may not take place precisely in these orderly steps. However, pathologists have developed these classifications as indicators of the progression of the disease.
Anatomy of ductal carcinoma in situ


Ductal carcinoma in situ (DCIS) is an overgrowth of abnormal cells in the milk ducts of the breast. It starts with the proliferation of normal cells lining the milk ducts (ductal hyperplasia); next, the cells within the duct become abnormal and rapidly multiply (atypical ductal hyperplasia); finally, abnormal cells fill the duct (DCIS). Invasive ductal breast cancer occurs when abnormal cells break out of the milk duct.

Diagnosing DCIS
Like other types of cancer, DCIS is usually diagnosed by a team of medical professionals (including radiologists, surgeons, and pathologists), using the following techniques:

Mammography. In a sense, increased use of mammography is responsible for the increase in DCIS, because it has increased detection. Confined to the ducts, DCIS tumors are often too small to cause symptoms or to be felt on a breast exam. Before mammograms became routine in the late 1970s, DCIS was usually discovered incidentally during a biopsy or autopsy, and it was thought to be rare, constituting fewer than 1% of breast cancers. Today, DCIS is likely to be identified during an annual mammogram that reveals tiny calcium deposits — microcalcifications — which appear as lines or clusters on an x-ray image and are sometimes associated with cancer. As mammography improves, so does the diagnosis of DCIS. In 2005, the last year for which statistics are available, DCIS accounted for more than 20% of newly diagnosed breast cancers.

Magnetic resonance imaging (MRI) is now increasingly used in breast imaging, but it hasn't yet been found significantly better than mammography in screening for DCIS.

Biopsy. Once DCIS is suspected, a biopsy is needed to determine whether cancer is actually present and, if so, the extent of the disease. These days, biopsies are more likely to be performed in the radiology suite than in the operating room. In the most commonly used procedure, stereotactic core biopsy, a large needle or thin vacuum tube is guided by ultrasound into the region of the breast containing microcalcifications to take a tissue sample. However, when mammography has indicated large areas of microcalcification, a surgical biopsy may be recommended.

Pathology. Pathologists examine the biopsy sample to determine how far the tissue has strayed from normal breast tissue. They look at the structure and arrangement of the cells under a microscope and may test the sample to determine the presence of receptors for estrogen and progesterone or abnormalities in genes associated with cancer.

By considering the features and growth pattern of the cells, they will characterize the disease as low grade, intermediate grade, or high grade — a classification that reflects how different the tumor cells look from normal cells and how quickly the tumor is likely to grow.

Treating DCIS
The data are limited on treating modern DCIS — which is identified by screening mammogram instead of being found rarely in large tumor masses. Until the 1980s, DCIS was routinely treated in the same way as most invasive cancers — with mastectomy.

That situation began to change after a large ongoing study, the National Surgical Adjuvant Breast and Bowel Project (NSABP), reported in 1983 that women with small invasive tumors who underwent lumpectomy followed by radiation were just as likely to survive as the women who underwent mastectomy. Physicians naturally assumed that the same approach could also work for patients with DCIS, and that assumption has been confirmed by large studies from the NSABP and the European Organization for Research and Treatment of Cancer.

Treatment decisions
Today, the results of mammography and biopsy determine the choice between mastectomy and lumpectomy. DCIS is never an emergency, so you can take a few weeks to weigh your options, which include the following:
  • Breast-conserving surgery (lumpectomy) is often recommended when DCIS is limited to one site and the tumor can be removed with a clear margin — several millimeters — of healthy tissue.
  • Radiation therapy is recommended for all women who have had breast-conserving surgery, because it reduces the chance of recurrence after surgery from 30% to 15%. The standard procedure is full-breast radiation administered in a hospital or center five days a week for five to eight weeks. Newer approaches are on the way (see "Future directions in DCIS").
  • Tamoxifen (Nolvadex) may further reduce the recurrence rate. In a randomized controlled NSABP study reported in 1999, women who received tamoxifen after surgery and radiation for DCIS were only half as likely to have a recurrence within five years, compared with similarly treated women who got a placebo.
  • Mastectomy is associated with a 10-year disease-free survival rate of 98%. It's usually reserved for women who have DCIS in more than one part of the breast or in cases where removing the tumor and a margin of healthy tissue around it would require a disfiguringly large incision. Mastectomy is also recommended for women who have a recurrence of DCIS or invasive cancer at the same site. Some women may choose mastectomy because they want to avoid undergoing radiation, or because they want to reduce their risk of recurrence to the lowest level possible.
  • Because the risk of metastasis is so low, lymph node biopsy is not required for diagnosing DCIS, and adjuvant chemotherapy is not necessary in treating it.


Lobular carcinoma in situ, the other preinvasive disease

Despite its name, lobular carcinoma in situ (LCIS) technically isn't breast cancer, and it may not even be a precancerous condition. However, it is generally considered a risk factor for the disease. Although a handful of small studies (most including fewer than 200 women) have suggested that LCIS doesn't directly progress to invasive cancer, women with LCIS are four times more likely than average to develop invasive ductal cancer and 18 times more likely to develop invasive lobular cancer.

LCIS is a proliferation of abnormal cells in the milk-producing structures (lobules) of the breast. The incidence of LCIS has been rising steadily since the late 1980s, mostly among women ages 50 and over. And since 2000, incidence has increased only among those ages 50 to 69 — the group most likely to have regular mammograms.

LCIS doesn't produce lumps that can be felt during breast exams or microcalcifications that appear on a radiology screen. It's usually discovered by chance during a biopsy for a benign breast condition or an invasive form of cancer. It occurs in an estimated 0.5% to 3.8% of benign breast biopsies, but no one knows for certain how common it really is.
LCIS usually arises in several lobules of both breasts, so lumpectomy isn't an option. Instead, LCIS is managed in these ways:

  • Observation. Because LCIS is a continuing risk factor for cancer, regular breast exams and annual mammograms are a lifelong must. The aim is not to find additional LCIS but rather to detect any developing cancers at the earliest possible stage. MRI, which is recommended for women at high risk for breast cancer, is an increasingly promising option for following women with LCIS.
  • Preventive measures. Clinicians recommend either tamoxifen, which reduced cancer incidence in women with LCIS by as much as 56% in clinical trials, or a related medication, raloxifene. Bilateral mastectomy is not routinely recommended, although it may be considered in women with LCIS who have factors that significantly increase the risk for invasive breast cancer, such as the presence of a BRCA gene mutation.


Future directions in DCIS
DCIS research is directed mainly at improving treatment and, above all, at preventing progression to invasive disease. As researchers continue to study the pathology of DCIS, they are finding that certain tumor characteristics help predict the treatment most likely to reduce the chance of recurrence. For example, some forms of breast cancer require estrogen in order to grow; tumors that do are termed estrogen receptor–positive (ER-positive). Tamoxifen belongs to a class of drugs called selective estrogen-receptor modulators (SERMs), which act by blocking estrogen receptors. Tamoxifen is more likely to prevent a recurrence in women with ER-positive DCIS than in women with ER-negative disease.

The use of aromatase inhibitors, which block estrogen production in the peripheral tissues and breast tissue, is being investigated in a trial of postmenopausal women with ER-positive DCIS. For women whose DCIS is ER-negative but who have the HER-2/neu gene, researchers are exploring the use of trastuzumab (Herceptin) and lapatinib (Tykerb), which block the tumor growth factors produced by that gene.

Another promising area of investigation involves the short-term use of chemotherapy between diagnosis and surgery to alter the DCIS, so that tissue from the surgical resection can be used by researchers to assess molecular as well as pathologic evidence of response. Agents that can induce responses in the "right direction" — for example, slow or stop the growth of abnormal cells — may then be further evaluated for their potential in treatment or prevention.

A new way to administer radiation that is showing some promise in clinical trials is accelerated partial breast irradiation, in which the tumor site alone is treated for five days with a lighter dose of radiation. In another approach, intraoperative radiation therapy, a one-time dose of radiation is delivered to the involved area of the breast after the tumor has been removed but before the incision is closed.

The good news about DCIS
DCIS is sometimes classified as Stage 0 of breast cancer, the earliest stage of the disease. The question for women with this diagnosis is not "Will I live?" but "How much treatment will I need?" One of the biggest risks today is overtreatment. That, too, is changing, as researchers get better at distinguishing the types of tumors that can be subdued without extensive surgery or radiation. DCIS is one cancer that can truly be considered curable.

If you have DCIS, you might consider entering a clinical trial. You would get the best available care and might benefit from a new type of therapy or approach. At the very least, you would be contributing to much-needed knowledge about this condition. Check the National Cancer Institute's registry of clinical trials at www.cancer.gov/clinicaltrialswww.cancer.gov/clinicaltrials for a site near you.


Nerve block quells hot flashes in women with breast cancer


Harvard Women's Health Watch | September 2008

In the journals

Hot flashes and sleep disturbances are a common and often severe side effect of drugs used to treat and prevent breast cancer, including tamoxifen and aromatase inhibitors. Estrogen is the best way to relieve hot flashes, but it can fuel breast cancer growth, so women who’ve had breast cancer or are at increased risk for it should usually avoid hormone therapy. Other options — less effective and with side effects of their own — include herbal therapies and prescription medications such as antidepressants and the anti-epileptic drug gabapentin. Now, in a small pilot study of breast cancer survivors, researchers have found they can nearly eliminate severe hot flashes and nighttime awakenings, with virtually no side effects, by anesthetizing certain nerves in the neck — a procedure called stellate ganglion blockade (SGB). The findings, published in Lancet Oncology (June 2008), may also have implications for menopausal women with disabling hot flashes.
While its application to hot flashes is relatively new, SGB has been safely used for years to relieve pain in the face, head, neck, and upper arm. During the procedure, an anesthetic is injected into the stellate ganglion (see illustration), a cluster of nerve cells in the neck that help regulate blood flow and are linked to brain regions involved in body temperature regulation.

In the investigation, led by Dr. Eugene Lipov at Advanced Pain Centers in Hoffman Estates, Ill., 13 women whose breast cancer was in remission underwent x-ray image–guided SGB in the right side of the neck. The 10-minute procedure was performed under local anesthesia with optional mild sedation. For a week before and 12 weeks after treatment, the women logged the frequency and severity of their symptoms. Two weeks after the procedure, hot flashes had decreased from an average of 80 per week to 50, and night awakenings from 20 per week to seven. By the end of the three-month follow-up period, night awakenings were down to about one per week, and the women were having almost no hot flashes at all. Five of the women required only one SGB procedure, and the other eight required two. There were no adverse effects except Horner’s syndrome, a drooping eyelid that lasts for a few hours after the procedure and indicates that the blockade was properly placed.

The investigators concede that their findings are preliminary and more research is needed to prove that SGB will be effective and without complications for breast cancer survivors. (Lipov’s group published similar results in a handful of women with postmenopausal hot flashes in the October 2005 Journal of Women’s Health.) There are some drawbacks to the procedure: it requires special training to perform; it’s expensive (between $1,000 and $3,000); it’s not always covered by health insurance; and injected anesthetics could cause allergic or other adverse reactions. In future studies, the researchers will evaluate the safety and effectiveness of applying pulsed radiofrequency instead of injected anesthetics to the stellate ganglion.



More Radiation in Less Time




More Radiation in Less Time

By Laura Beil

The tantalizing idea of reducing radiation treatment time recently got a boost, and some researchers predict the approach may soon be offered to more women in the United States.

Radiation uses beams of high-energy X-rays to kill tumor cells and minimize recurrence in the breast. In breast cancer treatment, doctors have long worried about radiation’s potential to leave lasting injury on nearby healthy tissues, mostly the heart and lungs.

American women typically undergo treatment five days a week for around five to six weeks. Recent trials, however, have compared a different philosophy: hypofractionated radiation, which employs a larger dose on a shorter schedule. While quicker treatment sounds appealing, doctors have feared the higher doses might amplify the danger to the heart, bone, and muscle, and also lead to more scarring.

But studies have not found this to be the case. In 2002, Tim Whelan, MD, of McMaster University and Juravinski Cancer Centre in Ontario, described a randomized trial of more than 1,200 women, published in the Journal of the National Cancer Institute. Five years after treatment with a radiation schedule about half as long, women with early-stage breast cancer had results just as good as women receiving the longer schedule.

This past December, during the San Antonio Breast Cancer Symposium, Dr. Whelan and his colleagues revealed the 12-year picture from longer follow-up: The results remained practically equivalent. The risk of breast cancer recurrence at about 10 years was around 6 percent in both groups—6.7 percent with the standard schedule compared with 6.2 with the hypofractionated schedule—and the overall survival was about 84 percent in both groups.

Despite the appeal of more convenient treatment, questions remain. For example, heart problems caused by radiation—the chief long-term concern—may not emerge until 15 years after treatment or later, so some doctors believe the question of adverse effects can’t be entirely answered yet.

“It’s a very difficult problem to study,” says Abram Recht, MD, of Harvard Medical School and Beth Israel Deaconess Medical Center in Boston. Cardiovascular disease is the most common cause of death in the country, so vast numbers of women in studies are going to experience heart problems, regardless of how they receive radiation. “You’re trying to detect a small increase in a relatively large background rate,” Dr. Recht says.

Also unclear is which women would be the best candidates for hypofractionated treatment, and which should remain on the longer schedule. Patients in the Canadian trial tended to be those with the best prognoses, so whether the results apply to a larger population of women with cancer is unknown.

The majority of patients on the standard schedule get what’s called a “boost,” extra radiation in the tumor area, where the greatest chance of return exists. “The question is, can you add a boost to this fractionation scheme,” says Lori Pierce, MD, of the University of Michigan Health System. Without the data, she says, she would be wary of doing so.

Still, Dr. Pierce calls the recurrence rates in the new Canadian data “excellent.” Given the length of time patients have now been followed, she’s comfortable offering it to certain patients—for instance, those not receiving chemotherapy who live far from cancer centers and have difficulty traveling back and forth for weeks.

The data are already convincing enough that Dr. Recht has begun offering hypofractionated radiation to select patients: women with small- or medium-sized breasts who have low-grade tumors. However, like Dr. Pierce, he is wary of using the compacted schedule in women who are also receiving chemotherapy because the hypofractionated schedule hasn’t been well studied in combination with chemotherapy. And he still does not use it for treatment on the left breast, which delivers the radiation closer to the heart.

Another part of the hesitation he and his American colleagues have, Dr. Recht says, is simply overcoming decades of tradition. Radiation oncologists were taught the longer schedule, have long relied on it, and are comfortable with it.

Even if the data continue to look favorable, Dr. Recht says, a shift in clinical practice could take years to gain momentum. “It’s going to take Americans actually doing it,” he says.








Breast Reconstruction After Mastectomy

American Cancer Society




1. Introduction
2. New Choices in Breast Reconstruction
3. Goals of Reconstruction
4. Special Considerations in Breast Reconstruction
5. Types of Breast Reconstruction
6. Nipple and Areola Reconstruction
7. Your Plastic Surgeon
8. Before Surgery
9. After Breast Reconstruction Surgery
10. Breast Reconstruction and Cancer Recurrence
11. Our Reach to Recovery Program
12. Glossary
13. Additional Resources
14. References


1. Introduction


Breast reconstruction is a surgical procedure to restore the appearance of a breast for women who have had a breast removed (mastectomy) to treat breast cancer. The surgery rebuilds the breast so that it is about the same size and shape as it was before it was removed. The nipple and areola (the darker area surrounding the nipple) can also be added. Most women who have had a mastectomy can have reconstruction. Women who have had a lumpectomy usually do not need reconstruction. Breast reconstruction is done by a plastic surgeon.

This information is designed to give you the facts you need to make an informed decision about breast reconstruction. It will help you better understand the process and the words used when talking about breast reconstruction. The words in italics are further explained in the glossary at the end of this information.

The decision to have breast reconstruction is a matter of personal choice. Learn as much as you can about the process before making a decision. No single source of information can provide every fact or give you all the answers. You and those close to you should discuss any questions and concerns about reconstructive surgery with your health care team.

2. New Choices in Breast Reconstruction


Each year more than 240,000 American women face the reality of breast cancer. Today, the emotional and physical results are very different from what they were in the past. Great strides have been made in our understanding of this disease and its treatment. New approaches in treatment, as well as advances in reconstructive surgery mean that women who have breast cancer today have new and better choices.

More and more women with breast cancer are choosing surgery that removes less breast tissue than a mastectomy (removal of the entire breast). This is called breast conservation surgery (or lumpectomy or segmental mastectomy). However, some women choose (or need) a mastectomy. Some of those who have a mastectomy also choose to have reconstructive surgery to restore the breast's appearance.

If you are thinking about having reconstructive surgery, it is a good idea to discuss it with your surgeon and a plastic surgeon experienced in breast reconstruction before your mastectomy. This allows the surgical teams to plan the treatment that is best for you, even if you decide to wait and have reconstructive surgery later.

3. Goals of Reconstruction

Women choose breast reconstruction for different reasons. The goals of reconstruction are:

* to make your breasts look balanced when you are wearing a bra
* to permanently regain your breast contour
* to give the convenience of not needing an external prosthesis

The difference between the reconstructed breast and the remaining breast can be seen when you are nude. When the breasts are in a bra though, they should be close enough to one another in size and shape that you will feel comfortable about how you look in most types of clothing.

Your body image and self-esteem may improve after your reconstruction surgery, but this is not always the case. Breast reconstruction does not fix things you were unhappy about before your surgery. Also, you may be disappointed with how your breast looks after surgery. You and those close to you must be realistic about what to expect from reconstruction.

You should decide to have breast reconstruction only after you are fully informed about the procedure. There are often many options to think about as you and your doctors discuss what is best for you. The reconstruction process may require one or more operations. You should talk about the benefits and risks of reconstruction with your doctors before the surgery is planned. Give yourself plenty of time to make the best decision for you.

4. Special Considerations in Breast Reconstruction

Several types of operations can be done to reconstruct your breast. You can have a newly shaped breast with the use of a breast implant, your own tissue flap, or a combination of the two. A tissue flap is a section of your own skin, fat, and muscle which is moved from your tummy, back, or other area of your body to the chest area.

Immediate or Delayed Reconstruction with Breast Cancer

Immediate reconstruction is done at the same time as the mastectomy. A plus with immediate reconstruction is that the chest tissues are undamaged by radiation therapy or scarring. Also, immediate reconstruction means one less surgery.

Delayed reconstruction is done at a later time. For some women, this may be advised if radiation to the chest area is needed after the mastectomy. This is because radiation therapy that follows breast reconstruction can increase complications after surgery.

Decisions about reconstructive surgery depend on many personal factors such as:


* your overall health
* the stage of your breast cancer
* the size of your natural breast
* the amount of tissue available (for example, very thin women may not have
 enough extra body tissue to make flap grafts possible)
* your desire to match the appearance of the opposite breast
* your desire for bilateral reconstructive surgery and your insurance coverage for
 the unaffected breast and related costs
* the type of procedure
* the size of implant or reconstructed breast

Other important factors to consider:


* You may not want to think about this issue while you are coping with a diagnosis  of cancer. If this is the case, you may choose to wait until after your breast  
 cancer surgery to decide about reconstruction.
* You may simply not want to have any more surgery than is needed.
* Scarring is a natural outcome of any surgery, but skin necrosis (cell death) may
 occur if your ability to heal is impaired.
* Not all surgery is completely successful, and you may not be pleased with your
 cosmetic result.
* You may be concerned if you have bleeding or scarring tendencies.
* Your ability to heal may be hindered by previous surgery, chemotherapy,
 radiation, smoking, alcohol, diabetes, various medicines, and other factors.
* Is it your preference to have chemotherapy or radiation therapy after
 reconstruction or wait and have surgery after all treatment is completed?

* Breast reconstruction restores the shape of the breasts but cannot restore  
 your normal breast sensation. With time, the skin on the reconstructed breast
 can become more sensitive, but it will not give you the same kind of pleasure as
 before a mastectomy.
* Surgeons may suggest you wait for one reason or another. This may happen if
 you smoke or have other health conditions. Many surgeons require you to quit
 smoking at least 2 months before reconstructive surgery to allow for better
 healing. You may not be able to have reconstruction at all if you are obese, too
 thin, or have circulatory problems.
* The surgeon may recommend surgery to reshape the remaining breast to match
 the reconstructed breast. This could include reducing or enlarging the size of the
 breast or lifting the breast.
* Knowing your reconstruction options before surgery can help you prepare for a
 mastectomy with a more realistic outlook for the future.


5. Types of Breast Reconstruction

Implant Procedures

The most common implant is a saline-filled implant that has an external silicone shell and is filled with sterile saline (salt water). Silicone gel-filled implants are another option for breast reconstruction, but they are not used as often as they were in the past because of concerns that silicone leakage might cause immune system diseases. However, most of the recent studies show that implants do not increase the risk of immune system problems. Also, alternative breast implants that have different shells and are filled with different materials are being studied, but these are available only in clinical trials.

One-stage immediate breast reconstruction may be done at the same time as your mastectomy. After the general surgeon removes the breast tissue, a plastic surgeon places a breast implant where the breast tissue was removed to form the breast contour.

Two-stage immediate or two-stage delayed reconstruction is done if your skin and chest wall tissues are tight and flat. An implanted tissue expander, like a balloon, is placed beneath the skin and chest muscle. Through a tiny valve beneath the skin, the surgeon injects a salt-water solution at regular intervals to
fill the expander over time. After the skin over the breast area has stretched enough, the expander is usually removed in a second operation, and a permanent implant is put in its place. Some expanders are left in place as the final implant.

There are some important factors for you to think about when deciding to have implants:

* Your implants may not last a lifetime, so you may need more surgery to replace them.
* You can have local complications with breast implants such as rupture, pain, capsular contracture (scar tissue forms around the implant), infection, or an unpleasing cosmetic result. This means that implants may become less attractive over time.

Tissue Flap Procedures

Tissue flap procedures use tissue from your tummy, back, thighs, or buttocks to reconstruct the breast. The 2 most common types of tissue flap surgeries are the TRAM flap (transverse rectus abdominis muscle flap), which uses tissue from the tummy area, and the latissimus dorsi flap, which uses tissue from the upper back. These operations leave 2 surgical sites and scars, both from where the tissue was taken and on the reconstructed breast. The scars fade over time, but they will never go away completely. There can also be complications at the donor sites, such as abdominal hernias and muscle damage or weakness. There can also be differences in the size and shape of the 2 breasts. Because blood vessels are involved, these procedures usually cannot be offered to women with diabetes, connective tissue or vascular disease, or to smokers.

TRAM (transverse rectus abdominis muscle) Flap

The TRAM flap procedure uses tissue and muscle from the lower abdominal wall (tummy tissue). The tissue from this area alone is often enough to create a breast shape, and an implant may not be needed. The skin, fat, blood vessels, and at least 1 of the abdominal muscles are moved from the abdomen to the chest area. This procedure also results in a tightening of the lower abdomen, or a "tummy tuck." There are 2 types of TRAM flaps:

* Pedicle flap involves leaving the flap attached to its original blood supply
 and tunneling it under the skin to the breast area.
* Free flap means that the surgeon cuts the flap of skin, fat, blood vessels,
 and muscle free from its original location and then attaches the flap to blood
 vessels in the chest area. This requires the use of a microscope (microsurgery) to
 connect the tiny vessels and takes longer to finish than a pedicle flap. The free
 flap is not done as often as the pedicle flap but some doctors think that it can
 result in a more natural shape.




Latissimus Dorsi Flap

The latissimus dorsi procedure moves muscle and skin from your upper back when extra tissue is needed. The flap is made up of skin, fat, muscle, and blood vessels. It is tunneled under the skin to the front of the chest. This creates a pocket for an implant, which can be used for added fullness to the reconstructed breast. Though it is not common, some women may have weakness in their back, shoulder, or arm after this surgery.




DIEP (deep inferior epigastric artery perforator) Flap

A newer type of flap procedure, the DIEP flap, uses fat and skin from the same area as in the TRAM flap but does not use the muscle to form the breast mound. This procedure results in a tightening of the lower abdomen, or a "tummy tuck." The procedure is done as a "free" flap meaning that the tissue is completely detached from the tummy and then moved to the chest area. This requires the use of a microscope (microsurgery) to connect the tiny vessels. The procedure takes longer than the TRAM pedicle flap discussed above.


Donor Site

DIEP Flap





Gluteal Free Flap

This is another newer type of surgery that uses tissue, including the gluteal muscle, from the buttocks to create the breast shape. It is an option for women who cannot use the tummy sites due to thinness, incisions, failed tummy flap, or patient preference. The procedure is similar to the free TRAM flap mentioned above. The skin, fat, blood vessels, and muscle are detached from the buttock and then moved to the chest area. This requires the use of a microscope (microsurgery) to connect the tiny vessels.

6. Nipple and Areola Reconstruction

The decision to have your nipple and areola (the dark area around the nipple) reconstructed is up to you. Nipple and areola reconstructions are optional and considered the final phase of breast reconstruction. This separate surgery is done to make the reconstructed breast more closely resemble the original breast. It can be done as an outpatient under local anesthesia. It is usually done after the new breast has had time to heal (usually 3-4 months after surgery).

The ideal nipple and areola reconstruction requires symmetry in position, size, shape, texture, color, and projection. Tissue used to rebuild the nipple and areola is taken from your own body, such as from the newly created breast, opposite nipple, ear, eyelid, groin, upper inner thigh, or buttocks. Tattooing may be done to match the color of the nipple of the other breast and to create the areola.

Although it is done, saving and using the nipple from the breast with cancer that has been removed (called nipple saving or nipple banking) is not a good idea. Cancer cells may still be hidden in the nipple and the tissue is often injured by the cryopreservation process necessary for storage. Further research is needed in this area.

7. Your Plastic Surgeon

Once you decide to have breast reconstruction, you will need to find a board-certified plastic surgeon experienced in breast reconstruction. Your breast surgeon can suggest doctors for you.

To find out if a surgeon is board certified, contact the American Society of Plastic Surgeons (ASPS). This organization has a Plastic Surgery Information Service that provides a list of ASPS members in a caller's area who are certified by the American Board of Plastic Surgery. ASPS contact information is provided in the "Additional Resources" section toward the end of this document.

Questions to Ask

It is very important that you ask as many questions of your surgeon as you need to before having breast reconstruction. If you don't understand something, ask your surgeon about it. Here is a list of questions to get you started. Write down other questions as you think of them. You may want to record your conversations with your surgeons. It is also helpful to bring a friend or family member with you to the doctor to help you remember what was said. The answers to these questions may help you make your decisions.


* Am I a candidate for breast reconstruction?
* When can I have reconstruction done?
* What types of reconstruction are possible in my specific case?
* What is the average cost of each type? Does my insurance cover them?
* What type of reconstruction is best for me? Why?
* How much experience do you (plastic surgeon) have with this procedure?
* What results are realistic for me?
* Will the reconstructed breast match my remaining breast in size?
* How will my reconstructed breast feel to the touch?
* Will I have any feeling in my reconstructed breast?
* What possible complications should I know about?
* How much discomfort or pain will I feel?
* How long will I be in the hospital?
* Will I need blood transfusions? If so, can I donate my own blood?
* How long is the recovery time?
* What type of wound care will I need to do at home?
* How much help will I need at home to take care of my drain
and wound?
* When can I start my exercises?
* How much activity can I do at home?
* What do I do if I get swelling (lymphedema) in my arm?
* When will I be able to return to normal activity such as driving and working?
* Can I talk with other women who have had the same surgery?
* Will reconstruction interfere with chemotherapy?
* Will reconstruction interfere with radiation therapy?
* How long will the implant last?
* What kinds of changes to the breast can I expect over time?
* How will aging affect the reconstructed breast?
* What happens if I gain or lose weight?
* Are there any new reconstruction options that I should know about?


It is common to get a second opinion before having any surgery. Breast reconstruction and even mastectomy are not emergencies. It is more important for you to make the right decisions based on the correct information than to act quickly before you know all your options.

8. Before Surgery

You can begin talking about reconstruction as soon as you know you have breast cancer. You will want your breast surgeon and your plastic surgeon to work together to come up with the best possible plan for reconstruction.

After reviewing your medical history and overall health, your surgeon will explain which reconstructive options are best for your age, health, body type, lifestyle, and goals. Openly discuss your expectations. Your surgeon should be frank with you when talking about your risks and benefits for each option.

Breast reconstruction after a mastectomy can improve your appearance and renew your self-confidence. However, keep in mind that the desired result is improvement, not perfection.

If you would like to talk with someone who has had your type of surgery, our Reach to Recovery volunteers are trained to support people facing breast cancer, as well as those who have surgery, chemotherapy, radiation therapy, and who are thinking about breast reconstruction. Ask your doctor or nurse to refer you to a Reach to Recovery volunteer in your area, or call us at 1-800-ACS-2345.

Your surgeon should also explain the details of your surgery, including:

* the anesthesia he or she will use
* where the surgery will take place
* what to expect after surgery
* the plan for follow-up
* costs

Health insurance policies often cover most or all of the cost of reconstruction after a mastectomy. Check your policy to make sure you are covered. Also, see if there are any limits on what types of reconstruction are covered.

Be aware that some insurance companies will deny breast reconstruction costs if you have already submitted claims for a breast prosthesis.

Preparing for Your Surgery

Your breast surgeon and your plastic surgeon will give you specific instructions on how to prepare for surgery. These will likely include:

* guidelines on eating and drinking
* tips to quit smoking
* instructions to take or avoid certain vitamins and medicines for a period of time before your surgery

You should arrange for someone to drive you home after your surgery and to help you out for a few days.

Where Your Surgery Will Be Performed

Breast reconstruction often involves more than 1 operation. The first stage involves creation of the breast mound. Whether this is done at the same time as the mastectomy or later on, it is usually done in a hospital.

Follow-up procedures, such as creating the nipple and areola, may also be done in the hospital or in an outpatient facility. This decision depends on the extent of surgery needed and what your surgeon prefers.

Types of Anesthesia

The first stage of reconstruction is almost always done using general anesthesia, so you'll be asleep during the surgery.

Follow-up procedures may only require a local anesthesia to make the area numb with a sedative to make you drowsy. You'll be relaxed but awake, and you may feel some discomfort.

Possible Risks

Almost any woman who must have her breast removed because of cancer can have reconstructive surgery. Certain risks go along with any surgery, and reconstruction may have certain unique problems associated with it.

Some risks of reconstruction surgery are:

* bleeding
* fluid collection with swelling and pain
* excessive scar tissue
* infection
* tissue necrosis (death) of all or part of the flap
* problems at the donor site (immediate and long-term)
* changes in nipple and breast sensation
* fatigue
* the need for additional surgeries to correct problems
* changes in the affected arm
* problems with anesthesia

Risks of smoking

The use of tobacco causes constriction of the blood vessels and reduces the supply of nutrients and oxygen to tissues. As with any surgery, smoking can delay healing. This can result in scars that are more noticeable and a longer recovery time. Sometimes these complications are severe enough to require a second operation. You may be asked to quit smoking before surgery.

Risks of infection

Infection can develop with any surgery. This usually happens within the first 2 weeks after surgery. If an implant has been used, it may need to be removed until the infection clears. A new implant can be inserted later. If you have a tissue flap, surgical cleaning of the wound is usually done.

Risks of capsular contracture

The most common problem with breast implants is capsular contracture. This happens when the scar or capsule around the implant begins to tighten and squeezes down on the soft implant. It can make the breast feel very hard. Capsular contracture can be treated in several ways. Sometimes more surgery is needed to remove the scar tissue. The implant might also need to be removed or replaced.

9. After Breast Reconstruction Surgery

What to Expect

You are likely to feel tired and sore for a week or 2 after implant reconstruction and longer after flap procedures. Your doctor can give you medicines to control most of your discomfort.

Depending on the type of surgery, you should go home from the hospital in 1 to 6 days. You may be discharged with a surgical drain in place. The drain is needed to remove excess fluids from the site while it heals. Follow your doctor痴 exact instructions on wound and drain care. If you have any concerns or questions, call your doctor.

Getting Back to Normal

You should be up and around in 6 to 8 weeks. If implants are used without flaps, your recovery time may be less. Some things to remember:

* Reconstruction does not restore normal sensation to your breast, but some
 feeling may return.
* It may take as long as 1 to 2 years for tissues to completely heal and for scars to
 fade, but the scars never go away entirely.
* Follow your surgeon's advice on when to begin stretching exercises and normal
 activities. As a rule, you'll want to avoid any overhead lifting, strenuous sports,
 and sexual activity for 4 to 6 weeks following reconstruction.
* Women who have reconstruction months or years after a mastectomy may go
 through a period of emotional readjustment once they have their breast
 reconstructed. Just as it takes time to get used to the loss of a breast, you may
 feel anxious and confused as you begin to think of the reconstructed breast as
 your own. Talking with other women who have had reconstruction might be
 useful. Talking with a mental health professional may also help with these
 feelings.
* Silicone gel implants may open up inside the body without causing symptoms.
 Women with this type of implant should
have MRI scans of the breast starting 3
 years after surgery and every 2 years after that to detect this problem. If the
 silicone device ruptures, another surgery will be required to replace it.

For more information on coping after cancer, see After Diagnosis: A Guide for Patients and Families and Sexuality for the Woman Who Has Cancer and her Partner. You can have these documents sent to you by calling 1-800-ACS-2345.

10. Breast Reconstruction and Cancer Recurrence

Studies to date have shown that reconstruction has no known effect on the recurrence of breast cancer. It should not cause problems with chemotherapy or radiation treatment if cancer does recur.

If you are considering breast reconstruction, either with an implant or flap, you need to know that reconstruction rarely, if ever, hides a return of breast cancer. You should not consider this a significant risk when deciding to have breast reconstruction after mastectomy.

Talk to your doctors about mammograms.

It is important to have regularly scheduled mammograms on the opposite breast at a facility with technologists experienced in taking and reading mammograms. All doctors may not recommend mammograms for a breast reconstructed with an implant. Mammogram pictures can be impaired by implants; more so by silicone than saline filled. If you need a mammogram and your reconstruction involves an implant, be sure to get your mammograms done at an accredited facility with technologists trained in manipulating the implant to get the best possible images of the rest of the breast.

While studies have supported mammograms of tissue flap breast reconstructions, no standard recommendation is in place. It is recognized that reconstructed breasts can have a fatty appearance, surgical clips, and surgical scars visible on the mammogram, but abnormalities can also be seen. Cancer can come back in the skin or any remaining breast tissue at areas of breast reconstruction. If you have a tissue flap reconstruction, you may need to continue mammograms on both breasts. Discuss this with your plastic surgeon and oncologist.

Breast Self-Examinations

After breast reconstruction, you may choose to keep doing breast self-examination (BSE). Check both the remaining breast and the reconstructed breast at the same time. This will help you learn what is normal for you so that you can find any changes in the future. The reconstructed breast will feel different, and the remaining breast may change, too. Your doctor or nurse can help you understand what is normal so that you can notice and report any changes as quickly as possible. To learn how to do breast self-examination after mastectomy, ask your doctor or nurse, call us at 1-800-ACS-2345, or see our document,Breast Cancer: Early Detection.

11. Our Reach to Recovery Program

Reach to Recovery is an American Cancer Society volunteer visitation program. Breast cancer survivors are trained to respond to you and your family痴 concerns when facing the diagnosis, treatment, and effects of breast cancer.

In many locations, trained Reach to Recovery volunteer visitors who have had breast reconstruction are available to visit with you if you are thinking about this type of surgery. These visits are always free of charge.

To request a Reach to Recovery visit ask your doctor or nurse for a referral, contact us at 1-800-ACS-2345, or use the "Contact Us" button at www.cancer.org.

12. Glossary

Alternative breast implants:
implants that have different exterior shells and are filled with different materials. These are still being studied in clinical trials.

Anesthesia:
the loss of feeling or sensation caused by drugs or gases. General anesthesia causes loss of consciousness ("puts you to sleep"). Local or regional anesthesia numbs only a certain area.

Areola:
the darker area surrounding the nipple

Breast conservation surgery:
surgery to remove a breast cancer and a small area of normal tissue around the cancer without removing any other part of the breast. The lymph nodes under the arm may be removed, and radiation therapy is often given after the surgery. This method is also called lumpectomy, segmental excision, limited breast surgery, or partial or segmental mastectomy.

Breast implant:
a sac used to increase breast size or restore the contour of a breast after mastectomy. The sac is filled with sterile saltwater (saline) or silicone gel.

Breast reconstruction:
surgery that rebuilds the breast contour or shape after mastectomy. A breast implant or the woman's own tissue is used. If desired, the nipple and areola may also be recreated. Reconstruction can be done at the time of mastectomy or any time later.

Capsular contracture:
scar tissue formation around the implant that tightens and squeezes the implant. There are 4 grades of contracture (Grades I-IV) that range from normal and soft to hard, painful, and distorted.

Clinical trials:
studies of new treatments in patients. They are only done when there is reason to believe that the treatment being studied may be of value to patients.

Delayed reconstruction:
reconstructive surgery that is done at a later time, not at the time of the original mastectomy surgery

DIEP (deep inferior epigastric artery perforator) flap:
a type of flap procedure that uses fat and skin from the same area as in the TRAM flap, but does not use the muscle to form the breast mound

Free flap:
in this kind of surgery the tissue for reconstruction is moved entirely from another area of the body and the blood and nerve supplies are surgically reattached with special microscopes

Gluteal free flap:
a newer type of flap procedure that uses tissue and gluteal muscle from the buttocks to create the breast shape

Immediate breast reconstruction (also called one-stage reconstruction):
reconstructive surgery that is done at the same time as the mastectomy, when the entire breast is removed

Latissimus dorsi flap:
this procedure tunnels muscle, fat, and skin from the upper back to the chest to create a breast mound

Lumpectomy:
surgery that removes only the breast lump and a margin of normal tissue around it

Mastectomy:
surgical removal of the part or all of the breast, and sometimes other tissue. See also segmental mastectomy

Microsurgery or microvascular surgery:
procedure that uses microscopes and fine surgical instruments to reattach the blood and nerve supply to tissues that have been removed from another area

Necrosis:
cell and tissue death from lack of blood supply to the tissue

Pedicle flap:
tissue that is surgically removed but the blood vessels remain attached and are tunneled from the original site to the area the tissue is to be attached

Saline-filled implant:
has an external silicone shell and is filled with sterile saline (salt water)

Segmental mastectomy:
surgery that removes more breast tissue than a lumpectomy (up to one-quarter of the breast). Also called partial mastectomy or quadrantectomy

Silicone gel-filled implants:
breast implants filled with a synthetic material. Because of its flexibility, strength, and texture, it is similar to the natural breast. Silicone gel breast implants are now available for women who have had breast cancer surgery but additional follow-up is required to watch for possible rupture of the implant.

Tissue expander:
implanted, inflatable balloons under the skin are used to keep living tissues under tension. This causes new cells to form and the amount of tissue to increase. The surgeon inserts the balloon expander beneath the skin where the breast should be and periodically, over weeks or months, injects a saline solution to slowly expand the overlaying skin to create space for an implant.

Tissue flap reconstruction:
tissue for reconstruction that is surgically removed from another area of the body. It can be a pedicle (attached and tunneled) or free flap (unattached).

Transverse rectus abdominis muscle (TRAM) flap:
a procedure that uses tissue and muscle from the lower tummy wall to reconstruct a breast mound. It can be a pedicle (attached and then tunneled) or free flap (unattached).

Two-stage reconstruction:
a two-step procedure that is done if your skin and chest wall tissues are tight and flat. An implanted tissue expander is placed beneath the skin and chest muscle. It is like a balloon that is inflated with saline over time and an implant is surgically placed when the desired fullness of the expander is achieved.

13. Additional Resources

More Information from Your American Cancer Society

We have selected some related information that may also be helpful to you. These materials may be ordered from our toll-free number, 1-800-ACS-2345.

* After Diagnosis: A Guide for Patients and Families

* Breast Cancer

* Breast Cancer: Early Detection

* Breast Prostheses List

* Reach To Recovery

* Sexuality For Women and Their Partners

National Organizations and Web Sites*

In addition to the American Cancer Society, other sources of patient information and support include:

American Society of Plastic Surgeons (ASPS)
Telephone number: 1-888-4-PLASTIC (1-888-475-2784)
Internet address: www.plasticsurgery.org
Information about breast reconstruction and referral to a board certified plastic surgeon.

Food and Drug Administration Consumer Information Line
Telephone number: 888-463-6332
Internet Address: http://www.fda.gov or http://www.fda.gov/cdrh/breastimplants/indexbip.html
Information on breast implants

National Cancer Institute
Telephone number: 800-4-CANCER
TTY: 800-332-8615
Internet Address: http://www.cancer.gov or http://www.clinicaltrials.gov
Information on clinical trials and patient educational materials in Physician痴 Desk Query (PDQ)

Y-Me National Breast Cancer Organization
Telephone number: 800-221-2141 (National hotline)
Telephone number: 800-986-9505 (Spanish hotline)
Internet address: http://www.y-me.org
Y-ME materials and services include:

* a national hotline staffed by trained peer counselors who are breast cancer
 survivors (male and female)
* Men's Match Program, which matches men with other men who are supporting a
 wife or family member who has breast cancer
* materials about breast health (including fibrocystic breast changes) and breast
 cancer
* monthly educational and support meetings throughout the country
* information on comprehensive breast centers and treatment and research
 hospitals
* referral to support groups nationwide
* wig and prosthesis banks

Self-Help for Women with Breast or Ovarian Cancer (SHARE)
Telephone number: 866-891-2392 (toll free) or 212-382-2111
Internet address: http://www.sharecancersupport.org
SHARE operates 3 hotlines for anyone who has a concern about breast or ovarian cancer (the third is for Spanish callers). Hotline volunteers are breast or ovarian cancer survivors.

*Inclusion on this list does not imply endorsement by the American Cancer Society.

The American Cancer Society is happy to address almost any cancer-related topic. If you have any more questions, please call us at 1-800 ACS 2345 at any time, 24 hours a day.

14. References

Breast Reconstruction Following Breast Removal. American Society of Plastic Surgeons. Available at: www.plasticsurgery.org/public_education/procedures/breastreconstruction.cfm.

Farhadi J, Maksvytyte GK, Schaefer DJ, Pierer G, Scheufler O. Reconstruction of the nipple-areola complex: an update. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2006; 59: 40-53.

FDA Breast Implant Consumer Handbook - 2004. Available at: www.fda.gov/cdrh/breastimplants/indexbip.html.

Guerra AB, Metzinger SE, Bidros RS, Gill PS, Dupin CL, Allen RJ. Breast reconstruction with gluteal artery perforator (GAP) flaps. Annals of Plastic Surgery. 2004 Feb; 52(2): 118-125.

Kim SM, Park JM. Mammographic and ultrasonographic features after autogenous myocutaneous flap reconstruction mammoplasty. Journal of Ultasound in Medicine. 2004 Feb; 23(2): 275-82.

Kufe, DW, Pollack, RE, Weichselbaum, RR, Bast, RC, Gansler, TS, Holland, JF, Frei, E. Cancer Medicine, 6th ed. Hamilton, Ontario: B.C. Decker; 2003.

Resnick B, Belcher AE. Breast Reconstruction. American Journal of Nursing. 2002; 102: 26-33.

Taylor CW, Horgan K, Dodwell D. Oncological aspects of breast reconstruction. The Breast. 2005; 14: 118-130.

Winer EP, Morrow M, Osborne CK, Harris JR. Malignant Tumors of the Breast. In DeVita VT, Hellman S, Rosenberg SA (eds) Cancer Principles and Practice on Oncology, 6th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2001.

Revised: 09/06/2007



Femara(R) helps protect against return of breast cancer even when treatment starts several years after completing tamoxifen therapy




Femara(R) helps protect against return of breast cancer even when treatment starts several years after completing tamoxifen therapy

● Post-unblinding analysis of MA-17 trial data provides evidence for potential
benefit of starting Femara up to seven years after finishing tamoxifen

● Femara only member of aromatase inhibitor class with data demonstrating this
potential benefit, as published in Journal of Clinical Oncology

● Half of all breast cancer recurrences occur five or more years after diagnosis

● Separate analysis published in Annals of Oncology affirms significant advantages of Femara when taken after standard tamoxifen therapy

East Hanover, March 10, 2008— Women may reduce the risk of their breast cancer returning by starting treatment with Femara(R) (letrozole tablets) anywhere from one to seven years after finishing tamoxifen therapy, according to a new analysis published today in the Journal of Clinical Oncology(1).

The exploratory analysis of post-unblinding results from the landmark MA-17 trial, led by the National Cancer Institute of Canada Clinical Trials Group, evaluated a subset of women in the original placebo group when the study was unblinded.

The analysis shows that women who started Femara several years after completing the recommended five years of tamoxifen reduced their risk of breast cancer coming back by 63% compared to those who did not start Femara(1). In addition, the risk of cancer spreading to other areas of the body was reduced by 61%. The median period before starting Femara was 31 months.

“The important message for women is that it may never be too late for many breast cancer survivors to do more to protect themselves against the ongoing risk of disease recurrence,” said Paul Goss, M.D., PhD., of the Massachusetts General Hospital in Boston and the lead investigator of MA-17. “These data reinforce the need for women diagnosed with breast cancer to go back to their doctors and continue to discuss ways to reduce their risk of recurrence.”

More than 50% of breast cancer recurrences and deaths occur five or more years after completing tamoxifen treatment(1). Femara is the only drug in the aromatase inhibitor class with data showing its potential to reduce the risk of breast cancer returning even when started several years after initial treatment with tamoxifen.

A separate intent-to-treat analysis of unblinded results from the MA-17 trial, published today in the Annals of Oncology,supports the significant benefit of initiating Femara within three months of completing five years of tamoxifen(2). If women do not have the opportunity to begin Femara treatment within three months of completing tamoxifen, the exploratory analysis published in the Journal of Clinical Oncology indicates they may still benefit from starting Femara up to several years later.

MA-17 was an international, double-blinded, randomized, multi-center Phase III trial to evaluate the effectiveness of Femara versus placebo in breast cancer survivors who had completed five years of tamoxifen treatment. It was led by the National Cancer Institute of Canada Clinical Trials Group at Queens University in Kingston, Ontario with funding from the Canadian Cancer Society and support from Novartis.

The trial was unblinded in 2003 after the first planned interim analysis showed a marked benefit for Femara in reducing the risk of breast cancer recurrence(2). At that time, women in the placebo arm were offered the chance to start treatment with Femara or to continue without additional treatment.

The analysis published in the Journal of Clinical Oncology evaluated the subset of 2,383 women who were in the placebo group when the MA-17 trial was unblinded. Of these women, 1,579 chose to switch to Femara, while 804 chose not to start Femara. The safety analysis was consistent with many other Femara trials in various treatment settings, reinforcing that Femara is well tolerated.

“Novartis has the highest level of commitment to ensuring that women with breast cancer have the knowledge and therapies to reduce their risk of recurrence, whether they were diagnosed yesterday or many years ago,” said Diane Young, M.D., Head of Global Medical Affairs at Novartis Oncology. “Femara offers protection against recurrence throughout several phases of breast cancer treatment in women with hormone-sensitive early breast cancer. These new data add to the body of clinical evidence for Femara.”

The intent-to-treat analysis published in the Annals of Oncology evaluated the outcomes for women assigned to Femara and placebo in the original trial study arms. At a median follow-up of 64 months, Femara significantly reduced the risk of breast cancer recurrence by 32% versus placebo. Femara maintained its significant benefit over placebo, even though more than 60% of women in the placebo group started Femara when the study was unblinded.

Results from this analysis affirm the safety and efficacy of Femara as extended adjuvant therapy (i.e. following the completion of five years of tamoxifen).

About Femara
Femara(R) (letrozole tablets) is approved for the adjuvant (following surgery) treatment of postmenopausal women with hormone receptor-positive early stage breast cancer. The benefits of Femara in clinical trials are based on 24 months of treatment. Further follow- up will be needed to determine long-term results, safety and efficacy.

Femara is also approved for the extended adjuvant treatment of early stage breast cancer in postmenopausal women who are within three months of completion of five years of tamoxifen therapy. The benefits of Femara in clinical trial are based on 24 months of treatment. Further follow-up will be needed to determine long-term results, including side effects.

In addition, Femara is approved for the treatment ofpostmenopausal women with estrogen receptor-positive or estrogen receptor-unknown breast cancer that has spread to another part of the body (metastatic cancer).


Important Safety Information
You should not take Femara if you are premenopausal. Your doctor should discuss the need for adequate birth control if you have the potential to become pregnant, if you are not sure of your postmenopausal status, or if you recently became postmenopausal. Femara is only indicated in postmenopausal women. Talk to your doctor if you’re allergic to Femara or any of its ingredients. You should not take Femara if you are pregnant as it may cause fetal harm. Some women reported fatigue and dizziness with Femara. Until you know how it affects you, use caution before driving or operating machinery. Some patients taking Femara had an increase in cholesterol. Additional follow-up is needed to determine the risk of bone fracture associated with long-term use of Femara.

In the adjuvant setting, commonly reported side effects are generally mild to moderate. The most common side effects seen with Femara include hot flashes, joint pain, night sweats, weight gain, nausea, tiredness, other heart-related events and bone fractures. Other less commonly reported side effects include vaginal bleeding, blood clots, other cancers, osteoporosis, stroke, heart attack and endometrial cancer.

In the extended adjuvant setting, commonly reported side effects are generally mild to moderate. Commonly reported side effects for Femara include hot flashes, fatigue, joint pain, headache, increase in sweating, swelling due to fluid retention, increase in cholesterol, dizziness, constipation, nausea, cardiovascular ischemic events, muscle pain, osteoporosis, arthritis and bone fracture.

In the metastatic cancer setting, commonly reported side effects are generally mild to moderate and may include bone pain, hot flashes, back pain, nausea, joint pain, shortness of breath, tiredness, coughing, constipation, limb pain, chest pain and headache.

Disclaimer
The foregoing release contains forward-looking statements that can be identified by terminology such as “potential”, “may”, “to be”, or similar expressions, or by express or implied discussions regarding potential new indications or labelling for Femara or regarding potential future revenues from Femara. Such forward-looking statements reflect the current views of the Company regarding future events, and involve known and unknown risks, uncertainties and other factors that may cause actual results with Femara to be materially different from any future results, performance or achievements expressed or implied by such statements. There can be no guarantee that Femara will be approved for any additional indications or labelling in any market. Nor can there be any guarantee that Femara will achieve any particular levels of revenue in the future. In particular, management’s expectations regarding Femara could be affected by, among other things, unexpected clinical trial results, including unexpected new clinical data and unexpected additional analysis of existing clinical data; unexpected regulatory actions or delays or government regulation generally; the company’s ability to obtain or maintain patent or other proprietary intellectual property protection; competition in general; government, industry and general public pricing pressures, and other risks and factors referred to in Novartis AG’s current Form 20-F on file with the US Securities and Exchange Commission. Should one or more of these risks or uncertainties materialize, or should underlying assumptions prove incorrect, actual results may vary materially from those anticipated, believed, estimated or expected. Novartis is providing the information in this press release as of this date and does not undertake any obligation to update any forward-looking statements contained in this press release as a result of new information, future events or otherwise.

About Novartis
Novartis Pharmaceuticals Corporation researches, develops, manufactures and markets leading innovative prescription drugs used to treat a number of diseases and conditions, including those in the cardiovascular, metabolic, cancer, organ transplantation, central nervous system, dermatological, gastrointestinal and respiratory areas. The company's mission is to improve people's lives by pioneering novel healthcare solutions.

Located in East Hanover, New Jersey, Novartis Pharmaceuticals Corporation is an affiliate of Novartis AG (NYSE: NVS), a world leader in offering medicines to protect health, cure disease and improve well-being. Our goal is to discover, develop and successfully market innovative products to treat patients, ease suffering and enhance the quality of life. We are strengthening our medicine-based portfolio, which is focused on strategic growth platforms in innovation-driven pharmaceuticals, high-quality and low-cost generics, human vaccines and leading self-medication OTC brands. Novartis is the only company with leadership positions in these areas. In 2006, the Group's businesses achieved net sales of USD 37.0 billion and net income of USD 7.2 billion. Approximately USD 5.4 billion was invested in R&D. Headquartered in Basel, Switzerland, Novartis Group companies employ approximately 100,000 associates and operate in over 140 countries around the world. For more information, please visit



References
1. Goss PE, Ingle JN, Pater JL, et al. Late extended adjuvant treatment with letrozole improves outcome in women with early-stage breast cancer completing 5 years of tamoxifen. J Clin Oncol. 2008

2. Ingle1 JN, Tu D. Pater JL , et al. Intent-to-treat analysis of the placebo-controlled trial of letrozole for extended adjuvant therapy in early breast cancer: NCIC CTG MA.17. Annals of Oncology. 2008

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Media Contacts

Megan Humphrey
Novartis Pharmaceuticals Corporation
1-862-778-6724
megan.humphrey@novartis.com

Dana Kahn Cooper
Cooper Communications
1-732-239-6664
dana@dcoopercommunications.com

What to do about high Cholesterol?


Harvard Health Publications,
February 5, 2008

Lower cholesterol safely and cheaply

One of the safest and cheapest ways to treat high cholesterol is to change your eating habits. In a nutshell: Eat less saturated and trans fats.

Your goal: no more than 25% to 35% of your total daily calories from fat, keeping your saturated fat intake to less that 7% of total calories and limiting dietary cholesterol to 200 mg or less per day. How can you tell how much and what kind of fat you’re getting? The labels on packaged foods and a calorie counter that includes fat grams are useful tools to help you determine fat calories.

Another tip: saturated fats are solid to semi-solid at room temperature and include the fats in meat, dairy products, and eggs, as well as some vegetable oils, particularly the tropical oils (palm, palm kernel, coconut, and cocoa butter). Most saturated fats stimulate LDL production in the body. Reducing the amount of saturated fat in your diet can lower your LDL.

On the other hand, unsaturated fats, which tend to be liquid at room temperature, include both monounsaturated and polyunsaturated fats. Olive, peanut, sesame, and canola oils are rich in monounsaturated fats, while soybean, corn, cottonseed, safflower, sunflower, and fish oils are high in polyunsaturated fats. In contrast to LDL-raising saturated fats, both monounsaturated fats and polyunsaturated fats have some ability to lower LDL.

Avoid trans fats, which are created when food manufacturers solidify unsaturated liquid oils to create firmer margarines and shortenings. Trans fats have been shown to raise LDL and lower HDL levels in the blood. These fats are a greater risk to heart health than even saturated fats. An expert panel from the Institute of Medicine concluded that trans fats have no known health benefit and that there is no safe level of consumption. Growing data on the hazards of trans fats prompted the FDA to pass a regulation that now requires nutrition labels to include trans fat content.

Monounsaturated fats do not undergo modification, and, when substituted for saturated fats, can help lower LDL cholesterol levels. Replacing saturated fats with monounsaturated fats — for example, using olive oil instead of butter — is one way to improve a wayward lipid profile, as long as you aren’t just adding monounsaturated fats and forgetting to cut back on the saturated fats.

Other diet changes that will help lower cholesterol include eating more fiber, such as that found in oat bran, and increasing your consumption of plant stanols and sterols, which are found in a number of food products. Plant stanol margarines such as Benecol and Take Control are worth trying, since regular use can help lower LDL cholesterol levels.
Research shows that genetic and physiological differences influence how dietary fat affects cholesterol levels. To maximize the benefits of modifying fat intake to lower cholesterol, you should:

1. Determine whether diet changes work for you.
Say you decide to try a lower-fat, lower-cholesterol diet for three to six months, but at the end of the trial period, a blood test shows that your cholesterol levels haven’t budged. You may belong to the nonresponder group and need a different kind of diet, or medication, to control your cholesterol.

2. One size doesn’t fit all.
When a friend or relative tells you how much his or her cholesterol level dropped after trying a particular diet, you may be tempted to try it too. But if after a few months you discover that the diet has no effect, remember, there isn’t a one-size-fits-all recommendation for fat or cholesterol consumption. You may have to try several different diet and exercise approaches to find one that works for you.



Bad Cancer Tests Drawing Scrutiny

The Wall Street Journal Jan 4, 2008
By Anna Wilde Mathews

Thousands of breast-cancer patients may be getting the wrong treatment because of errors in two laboratory tests widely used to determine which drugs are prescribed.

The tests are used to help determine whether women with invasive breast cancer will receive drugs such as Genentech Inc.'s Herceptin, GlaxoSmithKline PLC's Tykerb and a number of antihormone medications, including the generic tamoxifen and newer treatments such as AstraZeneca PLC's Arimidex and Faslodex.

The pharmaceuticals industry is trying to develop more medicines tailored to the individual characteristics of patients and their diseases. Herceptin, which went on the market in 1998, has been hailed as a breakthrough because it is designed for a certain subset of breast-cancer patients rather than everyone who has the disease.

But recent studies that turned up problems in testing point to a potential snag for such drugs: They depend on accurate lab results.

"We all make the assumption that every test is done well. It turns out it's not a correct assumption," says Lee Newcomer, a cancer doctor who is senior vice president at insurer UnitedHealth Group Inc. Several major private insurers, including UnitedHealth, Aetna Inc. and WellPoint Inc., say they will generally pay for second-opinion breast-cancer tests. However, Dr. Newcomer says that even though UnitedHealth covers a second test, few doctors order them.

In 2007, around 178,000 patients were expected to be diagnosed with invasive breast cancer in the U.S., according to the American Cancer Society. The tests relating to Herceptin and the antihomone drugs are less straightforward than many traditional lab procedures. They require pathologists to make judgment calls after looking at tissue through a microscope, rather than giving simple yes-or-no answers as in a pregnancy test.

One test examines whether a patient's tumor cells have too much of a protein called Her-2. If they do, Herceptin can help by targeting and destroying those cells. The other test checks for the presence of cell proteins that serve as receptors for the hormones estrogen or progesterone. These hormones can help tumors grow, so if the test is positive, doctors often prescribe drugs such as tamoxifen to suppress or block the hormones.

Karen Ivester, a manager at a construction firm in Boca Raton, Fla., was first diagnosed with breast cancer in 2002, when a marble-sized tumor was removed from her right breast. Ms. Ivester, 50 years old, says the local lab found her negative on both tests, meaning she wasn't given Herceptin or hormone therapy. She weathered chemotherapy and radiation.

Last year, after Ms. Ivester had a shooting pain in her ribs during a golf match, doctors found her cancer had returned in the bones of her spine. The new tumor tested positive on the hormone test. More surprisingly, so did her 2002 tumor, which was retested. Her current doctor, Chuck Vogel, says early use of tamoxifen might have headed off or delayed the cancer's return.

"I was absolutely, absolutely furious to know it was wrong, it could have been wrong," Ms. Ivester says. "I lost my first line of defense, and who knows what difference it would have made."

In a study published in 2006 on Her-2 tests -- led by researchers at Genentech -- a large laboratory that is experienced in the procedures reviewed tests performed by local labs around the country. It found that 14% to 16% of those judged positive for Her-2 were actually negative. Of those judged negative, 18% to 23% were in fact positive.

After signs of problems with hormone testing at a lab in Newfoundland, tissue from 763 patients with negative results was retested at a different lab in 2005 and 2006. The new tests concluded that 317 of those were actually positive. Officials at the provincial Eastern Regional Health Authority in Newfoundland, which oversees the lab that had inaccurate tests, said they can't comment on potential causes for the problems because of an ongoing government inquiry and a class-action suit by patients. But they said the authority did pursue the issue.

In another analysis of labs in multiple countries, published online last August in the Journal of Clinical Oncology, 70% of 105 patients scored as negative on the estrogen test were relabeled as positive when the tissue was retested by an experienced lab. The analysis found that positive results were almost always correct.

"If we tried to market pregnancy tests with this rate of inaccuracy, they would be taken off the market," says Allen Gown, chief pathologist of PhenoPath Laboratories, a Seattle lab. "It means there are a lot of women being treated inappropriately." When PhenoPath checked its performance on both breast-cancer tests using different methods, its results were consistent at least 95% of the time, he said.

In the U.S., such concerns could add momentum to efforts by Congress and consumer groups to push for increased oversight over the lab-testing business, which is booming because of factors such as the rise in genetic testing and the aging of the Baby Boom generation. In 2007, overall lab revenues grew 6.5% to around $51.7 billion, according to Washington G-2 Reports, a unit of the Bureau of National Affairs Inc.

"We're going to be looking at a future where diagnostic medicine will be the norm," says Pamela Klein, a vice president at Genentech. She says lab-testing consistency "can still be improved."

While every prescription drug must receive Food and Drug Administration approval, labs have considerable freedom to develop and perform their own tests. The FDA does approve certain testing kits, but labs can tweak the procedures without being required to get a regulatory sign-off on each home-grown method.

Lab-industry officials say this flexibility allows them to quickly translate emerging science into help for patients. They also say labs, which must be inspected every two years by outside examiners, receive strong oversight. "The process and the authority is there and it does work," says Alan Mertz, president of the American Clinical Laboratory Association, a trade group.

"Our system across the industry is a good one, and getting better," said Mara Aspinall, president of the genetics unit at Genzyme Corp., adding she is "very confident" of her own labs' tests.

However, Rolf Ehrnstrom, corporate vice president of research and development at Dako Denmark A/S, a maker of diagnostic tests and equipment manufacturer that sells both Her-2 and hormone-receptor test kits, said that if labs follow the recommendations in testing kits, "you have a much more standardized way of doing it," and the company believes "we need to standardize and make more quality-assurance throughout the labs."

Barry M. Straube, chief medical officer at the U.S. agency that regulates labs, the Centers for Medicare and Medicaid Services, says his agency is examining tougher quality-control requirements. Now labs must pass outside proficiency checks on only 83 types of tests. That list, devised in 1992, doesn't include the breast-cancer tests or dozens of others developed more recently.

"We're considering adding additional tests," Dr. Straube said. The two breast-cancer ones are likely candidates, he says. However, he says that, in general, "oversight is good."

Starting this year, the College of American Pathologists plans to require proficiency checks from the labs it oversees if they want to offer the Her-2 test. The college and the American Society of Clinical Oncology, which issued guidelines for the Her-2 test a year ago, estimated that around 20% of Her-2 testing may be inaccurate.The two groups also plan to look at the other breast-cancer test.

Some industry executives reject the notion that tests are often inaccurate. Joseph Purvis, executive director of clinical research oncology at drug maker AstraZeneca, says he hasn't seen evidence of extensive problems with hormone tests. "I don't think most patients should worry about the quality," he says.

But pathologists and cancer doctors say labs inexperienced in a particular test may not always understand how small variations in procedure can affect results. Reviews of hormone-receptor tests show that findings can change depending on how much the tissue samples are heated and what preservative is used.

Pathologists at Intermountain Healthcare, a hospital group based in Salt Lake City, found that results varied based on the day of the week a patient had surgery -- apparently because tissue that sat in a refrigerator or in preservative over the weekend was different from tissue examined quickly. Intermountain has since changed its procedures.

Hormone-testing methods are "a chaos," says Soonmyung Paik, director of the pathology division at the National Surgical Adjuvant Breast and Bowel Project, a nonprofit clinical research group, because "every lab uses a different method and different criteria to call a case positive."


Breast Cancer Suspects


Breast cancer clearly has a genetic component, but "routine environmental exposures and lifestyle may play a major role," according to a recent ground-breaking study by the Silent Spring Institute and Susan G. Komen for the Cure. The study, published in Cancer, a journal of the American Cancer Society, uncovers 216 common chemicals that cause breast tumors in animals and reviews medical literature, including some studies that reveal environmental factors to be influential "in the vast majority of cancers."


By Francesca Lyman for MSN Health & Fitness, Oct 2007


twelve breast cancer suspects identified by the researchers.


Tailpipe Toxins 

At the top of the list of common, potent mammary carcinogens are components of car and truck exhaust. Included on this list are PAHs (polycyclic aromatic hydrocarbons)—products of combustion—which have been linked to breast cancer in men as well as women.

Tobacco Smoke

Like car and truck exhaust, tobacco smoke is a source of many PAHs. Among these are dibenz[a,h]anthracene, considered by EPA to be “probably carcinogenic to humans” as well as mutagenic—meaning that it can cause genes to mutate. It’s laced with many other cancer-causing substances as well, such as dibenzo [def,p] chrysene.

Industrial Combustion Sources

Just as components of car exhaust have been linked to breast cancer and a long list of other illnesses, air pollution from refineries and coal plants also compounds the load. Researchers studying air pollution in Erie and Niagara counties in New York State found a higher risk of breast cancer among post-menopausal women whose birth addresses were near locations recording higher levels of PAHs. The researchers, who used historic air pollution data dating back to the 1960s to measure these trends, thus suggest that exposure in early life to high levels of PAHs may increase one's risk of postmenopausal breast cancer.

Drinking Alcohol

Most everyone agrees that limiting alcohol consumption can reduce the risk of breast cancer, but the connections get stronger with each new study. Natural cancer-causing substances—primarily urethanes—are found in alcohol, including wine and ale beers. In a recent analysis of six studies that examined 322,647 women, each additional 10 g of alcohol consumed equated to an added 9 percent risk of breast cancer.

Toxicants in Food

Food can be tainted by pesticides sprayed on crops, antibiotics used on poultry and other meats, and hormones injected into cattle, sheep and hogs. Some foods may increase the risk of breast cancer by increasing circulating levels of estrogen, so Silent Spring researchers advocate additional research in this area. They point to the fact that milk sold in the United States (banned in Canada and Europe) containing insulin-like growth factor 1 may put women at increased risk. Also, grilled or charred meat and fish contain various mutagenic agents that occur naturally in the grilling process.

Acrylamides—found in French fries, breads and cereals cooked at very high temperatures—pose problems, as do foods contaminated by styrene from polystyrene (Styrofoam) containers. Fish can also be contaminated with a variety of long-banned chemicals like PCBs, which have been linked to breast cancer, as well as by dioxin, a product of incineration.

Ionizing Radiation

In 2005, the National Toxicology Program classified x-rays and gamma radiation as causing cancer in humans, but ionizing radiation has long been regarded as the most established environmental risk factor for breast cancer.

We're exposed to x-radiation from medical x-rays, mammograms and other radiopharmaceutical treatments. Though these technologies offer great benefits, unnecessary exposure should be avoided.

Our greatest exposure to radiation is from the gamma rays in natural sunlight, which also provides us with beneficial Vitamin D. We get increased radiation from plane travel, as a result of greater proximity to the sun's rays and because the radiation is less filtered by clouds and particulates. If you live or work close to nuclear power plants or lived in the era of atmospheric testing of nuclear weapons (1945-1980) you will also have accumulated higher doses of this radiation. According to the National Toxicology Program, those radioactive doses are on the wane.

Hormone Supplements

Researchers broadly agree that women’s exposures to natural estrogens over time increases the risk of breast cancer. However, it is only recently that synthetic estrogens and progesterones have been linked to a higher risk for breast cancer.

Findings from the ongoing Million Women Study and the Women’s Health Initiative have found that certain kinds of Hormone Replacement Therapy (HRT), used to alleviate menopausal symptoms, put women at increased risk of breast cancer.

The U.S. Food and Drug Administration has advised women to ask their doctors about the benefits of taking estrogen and progestin compared to the risks—and, if they decide to use them, whether hormones should be taken “at the lowest doses for the shortest duration to reach treatment goals.”

Drinking Water Contaminants

Disinfecting products used to clean water help kill bacteria and keep disease in check. However, Silent Spring researchers caution that some disinfection byproducts of chlorinating water cause mammary tumors in rodents. There’s strong evidence for their causing cancer in humans as well. Likewise, many drinking water systems across the U.S. have been found to be contaminated by pesticides and dry cleaning chemicals.

Household Chemicals

Stain-resistant and flame-retardant chemicals have found their way into our lives—in our carpeting, furniture, clothing, cookware, cosmetics, lubricants, paints, and adhesives. Widely detected in blood samples in the US, PFOA (perfluorooctanoic acid) has been found to cause breast cancer in animals and is under further investigation.

Silent Spring Institute researchers also point to chlorinated solvents used in paint removers, varnishes, wood sealants, fabric cleaners, dry cleaning chemicals and septic tank cleaners as being suspected human carcinogens.

Gasoline, Benzene, Fuels and Solvents

Occupational studies have mainly focused on men, but a few studies on women workers have turned up elevated levels of breast cancer among those exposed to various petrochemical solvents—particularly women working in chemical factories and dry cleaning shops, hairdressers, nurses in health and science laboratories, and electronics industry workers. Benzene, to which we are exposed in gasoline at the pump and in lawn mowers and other appliances that might be stored in garages and basements, is a potent mammary carcinogen, according to Silent Spring researchers.

Pharmaceuticals

A wide variety of prescription drugs have been found to produce mammary tumors in animals—everything from Reserpine, used for the treatment of mild or moderate hypertension, to Furosemide for pulmonary edema. Many anti-cancer drugs are also known human carcinogens. Check the study's “browse” function under pharmaceuticals.

Miscellaneous Chemicals, Dyes, Whitening Agents

In January 2003, the federal Centers for Disease Control and Prevention reported their findings on human exposure to environmental chemicals, revealing some 116 toxic and cancer-causing chemicals in the blood and tissues of human volunteers chosen to represent our population. Among the compounds they found were multiple pesticides linked to breast cancer, dioxins that are products of incineration, and other chemicals.

Can our “body burdens” be lightened? Silent Spring researchers advocate reducing as many “preventable” exposures from industrial chemical byproducts as possible. Examples abound: 1,4 dioxane, a contaminant in detergents and shampoos, for example, and fluorescent whitening agents, both have been found to cause breast cancer in animals. The researchers argue that most chemicals used in hair dyes and cosmetics have not been tested for their health effects.

Francesca Lyman is the author of several environmental books, including The Greenhouse Trap and Inside the Dzanga-Sangha Rain Forest. Her work has appeared in The New York Times, The Washington Post, Ms. Magazine, Seattle Metropolitan, MSNBC Online, This Old House, and Horizon Air magazines.



BREAST-SPECIFIC GAMMA IMAGING WITH THE DILON 6800



BREAST-SPECIFIC GAMMA IMAGING WITH THE DILON 6800
The Dilon 6800 Gamma Camera enables optimized molecular breast imaging with a high-resolution, small field-of-view detector for image acquisition. The Dilon 6800 overcomes the limitations of a standard gamma camera through a patented detector that produces high contrast images of significantly smaller lesions and helps practitioners determine the presence or absence of cancer. The detector's compact size allows imaging close to the chest wall and in all standard mammographic views for direct correlation to mammograms. An additional benefit is that patients are able to sit comfortably throughout the image acquisition process, rather than lie prone as with standard gamma cameras.
BSGI, as a functional or molecular procedure, images cellular activity while both MRI and Ultrasound image tissue density. Functional imaging allows physicians to see the breast more clearly by accessing a map of cellular metabolism. Certain types of breast tissue may interfere with cancer detection. The need for a complementary diagnostic procedure to mammography is filled by a test that provides for improved sensitivity and specificity such as BSGI.

THE IDEAL DIAGNOSTIC COMPLEMENT TO MAMMOGRAPHY
Mammograms image tissue densities, not cancer activity. BSGI with the Dilon 6800 uses radiotracer uptake to detect cancer independent of tissue density.
With negative predictive values of 99%, and high sensitivity for lesions as small as 3 mm, BSGI with the Dilon 6800 has been integrated into the diagnostic protocol for challenging cases.
“In clinical studies lesions as small as 1mm have been reported by pathology- for both invasive cancer and DCIS. In addition, reports from studies and clinical practice demonstrate a high sensitivity for DCIS and lobular carcinoma.”

BSGI VS. MRI
MRI has shown usefulness as a next-step imaging modality for difficult-to-diagnose cases. Much like x-ray mammography, breast MRI relies on anatomical or structural information, but provides much more detailed images. It is limited however, by its highly variable specificity, which can range from below 37% to 97%. Combined with its high sensitivity, MRI produces a high false positive rate, is an expensive test to administer, is often difficult to schedule and may require multiple days to complete.
The specificity of BSGI/scintimammography has historically been higher than that of breast MRI. In addition, Dr. Petrovitch presented data at the 2005 RSNA showing that in the same patient population BSGI had comparable sensitivity, but higher specificity than breast MRI (High Resolution Molecular Breast Imaging with 99m-MIBI and Magnetic Resonance Imaging in the Assessment of Breast Cancer, 2005). There are also several factors which limit the use of breast MRI in patients.


BSGI VS. ULTRASOUND
Ultrasound is also commonly utilized as a next-step after a questionable mammogram and is good at determining if a suspect mass is solid or fluid-filled. However, ultrasound demonstrates a low specificity that can produce misleading results and indicate biopsy where one may not be needed.
BSGI, as a functional procedure, images cellular activity while both MRI and Ultrasound image tissue density. Functional imaging allows physicians to see the breast more clearly by accessing a map of cellular metabolism. Certain types of breast tissue may interfere with cancer detection. The need for a complementary diagnostic procedure to mammography is filled by a test that provides for improved sensitivity and specificity such as BSGI.

Comparison of Breast Imaging Modalities




Beth Israel Medical Center Offering new Breast Cancer Imaging Device

-New Technology Can Detect Cancer As Important Additive To Mammography-


Beth Israel Medical Center is the first hospital in New York City to begin using a new tool − Breast-Specific Gamma Imaging (BSGI) − to help identify cancerous breast tissue undetected by mammography.

Clinically proven effective in multiple studies, BSGI technology is particularly useful in serving as a complementary tool for radiologists and breast cancer specialists to detect breast cancer in women with difficult-to-read mammograms, such as those with dense breast tissue, breast implants or scar tissue from previous breast surgery. BSGI also is ideal for high-risk patients, including patients previously diagnosed with breast cancer, atypia and family history of cancer.

By operating on a cellular or molecular level, BSGI is not affected by tissue density and can help detect cancers at very early stages and allow for optimal intervention and treatment. Its ability to accurately detect breast cancer has the potential to significantly reduce the number of unnecessary, invasive biopsies. It also allows for accurate-pre surgical planning to help preserve healthy breast tissue.

“Mammography is still the first-line screening tool for breast cancer, but there are those challenging cases where it raises as many questions as it provides answers,” says Joshua Gross, MD, chief of the division of breast imaging at Beth Israel. “Mammography primarily measures differences in tissue density, but because dense tissue and cancers can have a similar appearance on mammography, it may be difficult to identify cancers (false negative mammograms) and in addition this may also lead to unnecessary biopsies (false positives mammograms).”

BSGI is provided at Beth Israel by the Dilon 6800 camera from Dilon Technologies, LLC. According to Sheldon Feldman, MD, chief of the Appel/Venet Comprehensive Breast Service at Beth Israel, the Dilon 6800 camera and its BSGI technology, which evolved from traditional nuclear medicine imaging (scintimammography), provides a better alternative to magnetic resonance imaging (MRI).

“MRI results can be difficult to interpret and thus has a significant ‘miss’ rate,” said Feldman, who, along with his breast surgeon colleague Susan Boolbol, MD, began offering the Dilon scan to applicable patients earlier this year. “MRI also is expensive, time consuming and a problem for claustrophobic patients. In comparison, BSGI is accurate and very quick to obtain, allowing a patient to receive same-day results. In addition, the Dilon camera requires no breast compression and the portable camera is small enough to fit in any breast center exam room.”

Scintimammography has long shown promise as a diagnostic tool for breast cancer detection, but the limitations of the procedure as performed with standard gamma cameras did not allow for the reliable detection of sub-centimeter lesions or direct correlation to mammograms. Advances in the technology of gamma detectors has led to the progression of a functional breast imaging procedure, BSGI, that is now achieved with anatomic-specific detectors, and in this case, optimized for high resolution breast imaging.

For more information on the use of the Dilon 6800 camera and BSGI technology at Beth Israel Medical Center, please call (800) 753-3229.


Oncotype DX Expands its Role in Guiding Optimal Treatment


Decisions in Women with Early Breast Cancer



Articles
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Doxil (R) Plus Gemzar(R) Active in Metastatic Breast Cancer
Brachytherapy May Be Just As Effective and More Convenient than Whole Breast Radiation for Breast Cancer

According to results recently presented at the 40th annual meeting of the American Society of Clinical Oncology (ASCO), the laboratory test called Oncotype DX(TM), which has already been approved for determining the risk of a recurrence in breast cancer, may also help detect which patients with breast cancer will respond to chemotherapy. Results from Oncotype DX(TM) may help guide patients to the most effective individualized treatment options for their cancer.

Breast cancer is responsible for approximately 40,000 deaths annually in the United States alone. However, if breast cancer is detected early, prior to the spread of cancer, cure rates remain high. Although patients with early breast cancer derive a significant survival benefit overall with the addition of chemotherapy in their treatment regimen, some women may be exposed unnecessarily to chemotherapy, suffering from side effects caused by the treatment while gaining no benefit. By using a test such as Oncotype DX(TM) to determine whether a patient is likely to achieve benefit from chemotherapy and/or is likely to expe- rience a cancer recurrence, physicians can tailor treatment to meet the needs of individual patients. This also allows patients who are not likely to benefit from specific chemotherapy agents to seek other treatment options.

Oncotype DX(TM) is a test that uses breast cancer biopsies, or small tissue samples, to determine whether a patient has breast cancer. The test analyzes the expression of specific genes or clusters of genes of the cancer cells and, through statistical analysis, can provide associations between the expression of one or more genes and specific outcomes of patients, such as risk of a cancer recurrence. Oncotype DX(TM) is presently approved to determine the risk of a distant recurrence in women with node-negative, estrogen receptor-positive breast cancer through the evaluation of 21 genes.

Researchers from Italy recently conducted a study to further evaluate Oncotype DX(TM) and its ability to predict an anti-cancer response to chemotherapy in women with early breast cancer. Previous studies have indicated that a complete disappearance of cancer following treatment upon evaluation under a microscope of a tissue sample, referred to as a pathologic complete response, has been demonstrated to improve cancer-free and overall survival in previous clinical studies. The study included 89 patients who had their biopsy specimens analyzed by Oncotype DX(TM) prior to any treatment. The patients were initially treated with a taxane (Taxotere (R) or paclitaxel), followed by the surgical removal of their cancer, followed by further chemotherapy with a regimen referred to as CMF (cyclophosphamide, methotrexate, 5-fluorouracil), radiation therapy and tamoxifen (Nolvadex (R)) if they were estrogen receptor-positive. Twelve percent of patients achieved a pathologic complete response. The results from Oncotype DX(TM) identified the expression of 86 genes that were associated with the achievement of a pathologic complete response. Expression of these genes tended to be from 3 gene groups: an estrogen receptor group, an immune group and a proliferation group. Patients with a higher expression of genes in the estrogen receptor group had a significantly lower rate of a pathologic complete response, while patients with a high expression of genes from the immune group and proliferation group had a higher rate of a pathologic complete response. Furthermore, when compared to the genes that predict for the risk of a distant recurrence, patients at a higher risk for a recurrence also have significantly higher rates of a pathologic complete response following treatment.

The researchers concluded that Oncotype DX(TM) helps predict a pathologic complete response following chemotherapy for patients with early breast cancer. The fact that patients who are identified to be at a high risk for developing a distant recurrence also tend to achieve pathologic complete responses following therapy led to greater evidence that these patients will achieve improved survival with additional treatment. Further studies will help elucidate exactly which patients will benefit from specified therapeutic approaches, leading the field of oncology into individualized treatment for patients.

Reference: Gianni L, Zambetti M, Clark K, et al. Gene expression profiles of paraffin- embedded core biopsy tissue predict response to chemotherapy in patients with locally advanced breast cancer. Proceedings from the 40th annual meeting of the American Society of Clinical Oncology. 2004. Abstract #501.

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