Breast Cancer

Managing

Following treatment for breast cancer, the patient must adjust to its effects, which can be temporary--such as hair loss during chemotherapy--or permanent, such as the loss of a breast. This adjustment may include using a prosthesis to replace a missing breast; taking medications, such as hormonal treatments, that have side effects; and dealing with fears of a recurrence as well as changes in the emotional landscape surrounding physical intimacy and sexuality. By all accounts, individuals who have experienced breast cancer should adopt a lifestyle that lessens, to the extent possible, the risk of a recurrence.

This section includes information on:

• Follow-up exams
• Managing lymphedema
• Using a prosthesis
• Sexual intimacy after treatment
• Hormonal treatment
• Exercise

Follow-up exams

People who have had breast cancer need regular follow-up examinations in the years after their treatment. The exact schedule will depend on individual circumstances. In general, however, routine care should involve visiting your doctor every three to six months for a physical exam and clinical breast exam, if you had a lumpectomy plus radiation, or an evaluation of the chest wall and unaffected breast if you chose mastectomy.

Regardless of the type of treatment, this schedule should continue for at least five years after treatment and then yearly thereafter. Breast self-examination each month is often suggested. Any change in breast tissue or nearby sites, as well as signs or symptoms that may suggest a recurrence, should be reported immediately to your healthcare provider. Signs include new, persistent pain in the bones, chest, or abdomen; weight loss, and shortness of breath. If you are taking tamoxifen and have not had a hysterectomy, you will need a yearly Pap test and pelvic examination because of the small risk of uterine cancer associated with this drug. If you have new symptoms, your doctor will recommend the necessary tests to determine whether they are associated with a metastatic recurrence.

Lymphedema

A breast cancer patient who has had lymph nodes removed from her armpit is at risk for lymphedema, the excessive accumulation of lymphatic fluid as a result of the absence of the nodes that help control its drainage. A woman has 35 to 40 nodes in each armpit; the greater the number of nodes surgically removed (especially if the number is more than seven), the more difficult it may be for lymphatic fluid to drain adequately.

The swelling that signals lymphedema is likely to start slowly. A slight puffiness is a sign that you should drink lots of water and pay close attention to the swelling. If it worsens, or if there is a sign of infection--the arm is red or warm to the touch and you are running a fever--contact your doctor. A physical therapist certified in lymphedema management may be able to reverse the swelling. A cancer doctor or breast cancer support group or breast cancer center may be able to recommend names.

Some steps a patient can take to reduce the likelihood of lymphedema:

• Avoid having your doctor check blood pressure or draw blood from the arm at risk. If you've had lymph nodes removed from both arms, you can offer your foot for blood draws and leg for blood pressure, or at least alternate arms.
• Good muscle tone helps the normal flow of the lymphatic system, so follow the exercise program prescribed by your healthcare provider. It's OK to lift weights. Just start at a low weight and work your way up to heavier weights.
• Make as much use as possible of the affected arm for ordinary purposes such as brushing the hair, washing the face, and the like.
• Drink six to eight glasses of water a day.
• Make every effort to prevent the arm and hand from becoming infected. This requires careful attention to cleanliness, scrupulous care of any cuts or bruises, daily use of skin creams to prevent dryness or chapping, and use of garments such as gloves and long sleeves to protect against injuries while gardening or doing chores.
• Guard against burning the skin, whether from kitchen injuries, hot showers or baths, or the sun. Use sunblock providing a sun protection factor (SPF) of at least 15.
• Wear loose-fitting garments and jewelry, especially when traveling by air.
• Avoid lifting objects heavier than you're used to.
• Don't carry a shoulder bag or grocery bag with the at-risk arm.
• When flying, walk about the cabin at least hourly to aid circulation.

Using a prosthesis

Women who opt out of reconstructive surgery after mastectomy often use a prosthesis in place of the missing breast. The silicone-filled breast form comes in a variety of shapes, sizes, and degrees of firmness. A prefab model costs about $250 to $500; a custom-made prosthesis, which can be made to match your remaining breast, could cost up to $3,000. (Insurance generally will cover the cost of a prosthesis up to about $500.) The higher-priced models generally have a more normal feel and more comfortable fit.

A Perma-Form bra, equipped with one or two built-in foam prostheses, is another option. While a silicone prosthesis looks and feels more natural, a Perma-Form bra is cooler on hot days. You should not attempt to purchase a prosthesis prior to surgery. Many hospitals will send a mastectomy patient home with a "puff," a small, breast-shaped pillow that can be slipped inside an undershirt. This can be used until you have healed from the surgery and are ready to shop for a prosthesis.

Sexual intimacy after treatment

Many women fear that the physical changes caused by breast surgery, not to mention the toll taken by chemotherapy and radiation, will have an impact on their intimate relationship with their partner. It's best for both members of a couple to communicate their needs and their fears. If your partner seems tentative after your surgery, you might take his or her hand and show where it's OK to touch and where your chest may feel tender. During the months of chemotherapy, intimacy is possible, but at times a patient may be too physically exhausted to think about sex. Chemotherapy can also cause vaginal dryness; vaginal lubricants can help.

Hormonal treatment

The medications tamoxifen or arimidex are usually prescribed for five years following cancer treatment. Research shows that tamoxifen, which blocks the ability of estrogen to attach to cells and promote their growth, reduces the risk that women who have had a "receptor positive" breast cancer--meaning their cancer cells have hormone receptors--will experience a recurrence of the original cancer or a new cancer. For women who are postmenopausal with early-stage breast cancer that is hormone-receptor positive, arimidex provides greater benefits; it works by reducing the level of estrogen in the blood. Evidence also suggests that for some postmenopausal women who have had receptor-positive breast cancer and completed five years of tamoxifen, taking the aromatase inhibitor letrazole for five additional years may be appropriate.

Thee are benefits to taking these medications, but women also experience side effects that can be bothersome and affect quality of life, especially hot flashes and night sweats. If women are experiencing these symptoms they should discuss them with their doctor to learn about different strategies for managing them.

Exercise

Exercise plays an important role in the well-being of many women who have had breast cancer. Women who have undergone a mastectomy will receive instructions on how to exercise to keep the affected arm and shoulder from losing strength and flexibility.

In addition, some evidence suggests that exercise helps lower the risk of recurrence. One study found that breast cancer survivors who walked just one to three hours a week at a pace of 3 miles per hour improved their chances of survival compared with sedentary breast cancer survivors. (Perhaps the walkers burn up fat that would otherwise produce estrogen, which can promote the growth of breast cancer). More strenuous exercise reduced the risk of dying from breast cancer even more.