Uterine Cancer

Uterine cancer facts

• The uterus is a hollow organ in females located in the pelvis, commonly called the womb. The uterus functions to support fetal development until birth. The uterus is shaped like an upside-down pear; the top is the fundus, the middle is the corpus, and bottom is the cervix; the inner layer of the uterus is the endometrium, and the outer layer is muscle (myometrium).
• Uterine cancer is the abnormal (malignant) growth of any cells that comprise uterine tissue. The buildup of cancer cells may form a mass (malignant tumor). Non-cancer cells that form a mass are termed benign tumors.
• Although the exact causes of uterine cancers are not known, risk factors include women with endometrial overgrowth (hyperplasia),obesity, women who have never had children, menses beginning before age 12, menopause after age 55, estrogen therapy, takingtamoxifen, radiation to the pelvis, family history of uterine cancer, and Lynch syndrome (most commonly seen as a form of inherited colorectal cancer).
• Common signs and symptoms of uterine cancer are
  
  • abnormal vaginal bleeding (most common symptom),
  • vaginal discharge,
  • pain with urination and/or sex, and
  • pelvic pains.
• Uterine cancer is diagnosed usually with a pelvic exam, Pap test, ultrasound, and biopsy. Occasionally, CT or MRI may be done to help confirm the diagnosis.
• Uterine cancer stages (0 to IV) are determined by biopsy, chest X-ray, and/or CT or MRI scans.
• Treatment options may include one or more of the following: surgery, radiation,hormone therapy, and chemotherapy. Treatment depends on the uterine cancer stage, your age, and general health with uterine cancer stage IV as the most extensive and usually caused by the most aggressive type of cancer cells. You and your doctors can decide what treatment plan is best for you.
• Surgical therapy usually involves removal of the uterus, ovaries, fallopian tubes, adjacent lymph nodes, and part of the vagina.
• Radiation therapy may be by external radiation or by internal radiation (brachytherapy).
• Chemotherapy usually requires IV administration of drugs designed to kill cancer cells. Most chemotherapy treatments need to be done in repeated cycles of drug administration followed by a rest period.
• Hormone therapy (usually progesterone) is used on uterine cancer cells that require another hormone (estrogen) for growth.
• Second opinions can be obtained by referrals made by your doctor to others in the local medical society or to other doctors elsewhere.
• Follow-up care is important. Complications can be treated early, and possible cancer recurrence can be diagnosed early.
• Support groups are varied and many are local. The National Cancer Institute (NCI) can help locate support groups and possible clinical trials that test the newest treatments.

Endometrial cancer is a disease in which malignant (cancer) cells form in the tissues of the endometrium.

The endometrium is the lining of the uterus, a hollow, muscular organ in a woman's pelvis. The uterus is where a fetus grows. In most nonpregnant women, the uterus is about 3 inches long. The lower, narrow end of the uterus is the cervix, which leads to the vagina.

Cancer of the endometrium is different from cancer of the muscle of the uterus, which is called sarcoma of the uterus.

Obesity, high blood pressure, and diabetes mellitus may increase the risk of endometrial cancer.

Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. Talk with your doctor if you think you may be at risk. Risk factors for endometrial cancer include the following:

• Being obese.
• Having high blood pressure.
• Having diabetes mellitus.

Taking tamoxifen for breast cancer or taking estrogen alone (without progesterone) can increase the risk of endometrial cancer.

Endometrial cancer may develop in breast cancer patients who have been treated with tamoxifen. A patient taking this drug should have a pelvic exam every year and report anyvaginal bleeding (other than menstrual bleeding) as soon as possible. Women taking estrogen (a hormone that can affect the growth of some cancers) alone have an increased risk of endometrial cancer. Taking estrogen combined with progesterone (another hormone) does not increase a woman's risk of this cancer.

Signs and symptoms of endometrial cancer include unusual vaginal discharge or pain in the pelvis.

These and other signs and symptoms may be caused by endometrial cancer or by other conditions. Check with your doctor if you have any of the following:

• Bleeding or discharge not related to menstruation (periods).
• Difficult or painful urination.
• Pain during sexual intercourse.
• Pain in the pelvic area.

Tests that examine the endometrium are used to detect (find) and diagnose endometrial cancer.

Because endometrial cancer begins inside the uterus, it does not usually show up in the results of a Pap test. For this reason, a sample of endometrial tissue must be removed and checked under a microscope to look for cancer cells. One of the following procedures may be used:

• Endometrial biopsy: The removal of tissue from the endometrium (inner lining of the uterus) by inserting a thin, flexible tube through the cervix and into the uterus. The tube is used to gently scrape a small amount of tissue from the endometrium and then remove the tissue samples. A pathologist views the tissue under a microscope to look for cancer cells.
• Dilatation and curettage: A procedure to remove samples of tissue from the inner lining of the uterus. The cervix is dilated and a curette (spoon-shaped instrument) is inserted into the uterus to remove tissue. The tissue samples are checked under a microscope for signs of disease. This procedure is also called a D&C.

Other tests and procedures used to diagnose endometrial cancer include the following:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient's health habits and past illnesses and treatments will also be taken.
• Transvaginal ultrasound exam: A procedure used to examine the vagina, uterus, fallopian tubes, and bladder. An ultrasound transducer (probe) is inserted into the vagina and used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. The doctor can identify tumors by looking at the sonogram.
• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

• The stage of the cancer (whether it is in the endometrium only, involves the whole uterus, or has spread to other places in the body).
• How the cancer cells look under a microscope.
• Whether the cancer cells are affected by progesterone.

Endometrial cancer is highly curable.

After endometrial cancer has been diagnosed, tests are done to find out if cancer cells have spread within the uterus or to other parts of the body.

The process used to find out whether the cancer has spread within the uterus or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. Certain tests and procedures are used in the staging process. Ahysterectomy (an operation in which the uterus is removed) will usually be done to help find out how far the cancer has spread.

The following procedures may be used in the staging process:

• Pelvic exam: An exam of the vagina, cervix, uterus, fallopian tubes, ovaries, and rectum. A speculum is inserted into the vagina and the doctor or nurse looks at the vagina and cervix for signs of disease. A Pap test of the cervix is usually done. The doctor or nurse also inserts one or two lubricated, gloved fingers of one hand into the vagina and places the other hand over the lower abdomen to feel the size, shape, and position of the uterus and ovaries. The doctor or nurse also inserts a lubricated, gloved finger into the rectum to feel for lumps or abnormal areas.
• Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
• PET scan (positron emission tomography scan): A procedure to find malignanttumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do. 

There are three ways that cancer spreads in the body.

Cancer can spread through tissue, the lymph system, and the blood:

• Tissue. The cancer spreads from where it began by growing into nearby areas.
• Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
• Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

Cancer may spread from where it began to other parts of the body.

When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.

• Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
• Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. For example, if endometrial cancer spreads to the lung, the cancer cells in the lung are actually endometrial cancer cells. The disease is metastatic endometrial cancer, not lung cancer.

The following stages are used for endometrial cancer:

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Stage I

In stage I, cancer is found in the uterus only. Stage I is divided into stages IA and IB, based on how far the cancer has spread.

• Stage IA: Cancer is in the endometrium only or less than halfway through the myometrium (muscle layer of the uterus).
• Stage IB: Cancer has spread halfway or more into the myometrium.

Stage II

In stage II, cancer has spread into connective tissue of the cervix, but has not spread outside the uterus.

Stage III

In stage III, cancer has spread beyond the uterus and cervix, but has not spread beyond the pelvis. Stage III is divided into stages IIIA, IIIB, and IIIC, based on how far the cancer has spread within the pelvis.

• Stage IIIA: Cancer has spread to the outer layer of the uterus and/or to the fallopian tubes, ovaries, and ligaments of the uterus.
• Stage IIIB: Cancer has spread to the vagina and/or to the parametrium (connective tissue and fat around the uterus).
• Stage IIIC: Cancer has spread to lymph nodes in the pelvis and/or around theaorta (largest artery in the body, which carries blood away from the heart).

Stage IV

In stage IV, cancer has spread beyond the pelvis. Stage IV is divided into stages IVA and IVB, based on how far the cancer has spread.

• Stage IVA: Cancer has spread to the bladder and/or bowel wall.
• Stage IVB: Cancer has spread to other parts of the body beyond the pelvis, including the abdomen and/or lymph nodes in the groin.

Recurrent Endometrial Cancer

Recurrent endometrial cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the uterus, the pelvis, in lymph nodes in the abdomen, or in other parts of the body.

There are different types of treatment for patients with endometrial cancer.

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Different types of treatment are available for patients with endometrial cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Five types of standard treatment are used:

Surgery

Surgery (removing the cancer in an operation) is the most 

common treatment for endometrial cancer. The following surgical procedures may be used:

• Total hysterectomy: Surgery to remove the uterus, including the cervix. If the uterus and cervix are taken out through the vagina, the operation is called a vaginal hysterectomy. If the uterus and cervix are taken out through a large incision (cut) in the abdomen, the operation is called a total abdominal hysterectomy. If the uterus and cervix are taken out through a small incision (cut) in the abdomen using a laparoscope, the operation is called a total laparoscopic hysterectomy.
• Bilateral salpingo-oophorectomy: Surgery to remove both ovaries and both fallopian tubes.
• Radical hysterectomy: Surgery to remove the uterus, cervix, and part of the vagina. The ovaries, fallopian tubes, or nearby lymph nodes may also be removed.

Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given radiation therapy or hormone treatment after surgery to kill any cancer cells that are left. Treatment given after the surgery, to lower the risk that the cancer will come back, is called adjuvant therapy.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy:

• External radiation therapy uses a machine outside the body to send radiation toward the cancer.
• Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.

The way the radiation therapy is given depends on the type and stage of the cancer being treated. External and internal radiation therapy are used to treat endometrial cancer, and may also be used as palliative therapy to relieve symptoms and improve quality of life.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Hormone therapy

Hormone therapy is a cancer treatment that removes hormones or blocks their action and stops cancer cells from growing. Hormones are substances made by glands in the body and circulated in the bloodstream. Some hormones can cause certain cancers to grow. If tests show that the cancer cells have places where hormones can attach (receptors), drugs, surgery, or radiation therapy is used to reduce the production of hormones or block them from working.

Biologic therapy

Biologic therapy is a treatment that uses the patient's immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body's natural defenses against cancer. This type of cancer treatment is also calledbiotherapy or immunotherapy.

New types of treatment are being tested in clinical trials.

This summary section describes treatments that are being studied in clinical trials. It may not mention every new treatment being studied.

Targeted therapy

Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells. Monoclonal antibodies and tyrosine kinase inhibitors are two types of targeted therapy being studied in the treatment of endometrial cancer.

Monoclonal antibody therapy is a cancer treatment that uses antibodies made in the laboratory from a single type of immune system cell. These antibodies can identify substances on cancer cells or normal substances that may help cancer cells grow. The antibodies attach to the substances and kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given by infusion. They may be used alone or to carry drugs, toxins, or radioactive material directly to cancer cells.

Tyrosine kinase inhibitors are targeted therapy drugs that block signals needed for tumors to grow. Tyrosine kinase inhibitors may be used with other anticancer drugs as adjuvant therapy.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.

Clinical trials are taking place in many parts of the country.

Follow-up tests may be needed.

Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests.

Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.

reatment Options by Stage

Stage I Endometrial Cancer

Treatment of stage I endometrial cancer may include the following:

• Surgery (total hysterectomy and bilateral salpingo-oophorectomy). Lymph nodes in the pelvis and abdomen may also be removed and viewed under a microscope to check for cancer cells.
• Surgery (total hysterectomy and bilateral salpingo-oophorectomy, with or without removal of lymph nodes in the pelvis and abdomen) followed by internal or external radiation therapy to the pelvis. After surgery, a plastic cylinder containing a source of radiation may be placed in the vagina to kill any remaining cancer cells.
• Radiation therapy alone for patients who cannot have surgery.
• Surgery followed by adjuvant chemotherapy with or without radiation therapy in stage I endometrial cancer that is likely to recur (come back).
• Clinical trials of new types of treatment.

Talk with your doctor about clinical trials that may be right for you.

Stage II Endometrial Cancer

Treatment of stage II endometrial cancer may include the following:

• Surgery (radical hysterectomy and bilateral salpingo-oophorectomy). Lymph nodes in the pelvis and abdomen may also be removed and viewed under a microscope to check for cancer cells. Radiation therapy may follow surgery.
• Surgery followed by adjuvant chemotherapy with or without radiation therapy in stage II endometrial cancer that is likely to recur (come back).
• Clinical trials of new types of treatment.

Talk with your doctor about clinical trials that may be right for you.

Stage III Endometrial Cancer

Treatment of stage III endometrial cancer may include the following:

• Surgery (radical hysterectomy and removal of lymph nodes in the pelvis so they can be viewed under a microscope to check for cancer cells) followed by adjuvant chemotherapy and/or radiation therapy.
• Chemotherapy combined with internal and external radiation therapy for patients who cannot have surgery.
• Hormone therapy for patients who cannot have surgery or radiation therapy.
• Combination chemotherapy with or without biologic therapy.
• Clinical trials of new types of treatment.

Talk with your doctor about clinical trials that may be right for you.

Stage IV Endometrial Cancer

Treatment of stage IV endometrial cancer may include the following:

• Surgery followed by chemotherapy and/or radiation therapy.
• Internal and external radiation therapy for patients who cannot have surgery.
• Hormone therapy for patients whose cancer has spread to distant parts of the body (such as the lungs).
• Combination chemotherapy with or without biologic therapy.
• Clinical trials of targeted therapy.
• Clinical trials of chemotherapy.

Talk with your doctor about clinical trials that may be right for you.

Treatment Options for Recurrent Endometrial Cancer

Treatment of recurrent endometrial cancer may include the following:

• Radiation therapy as palliative therapy to relieve symptoms and improve the patient's quality of life.
• Hormone therapy.
• Combination chemotherapy with or without biologic therapy.
• Clinical trials of targeted therapy.
• Clinical trials of chemotherapy.

Talk with your doctor about clinical trials that may be right for you.

Vaginal Yeast Infection

Vaginal yeast infection facts

• Most vaginal yeast infections are caused by the organism Candida albicans.
• Yeast infections are very common and affect up to 75% of women at some point in their lifetime.
• The main symptom of a vaginal yeast infectionis itching, but burning, discharge, andpain with urination or intercourse can also occur.
• Treatment involves topical or oral antifungal medications.
• It is possible for a woman to transmit a yeast infection to a male sex partner, even though yeast infection is not considered to be a true sexually-transmitted disease (STD) because it can occur in women who are not sexually active.
• Treatment of yeast infection in men, like in women, involves antifungal medications.
• Keeping the vaginal area dry and avoiding irritating chemicals can help prevent yeast infections in women. Consuming foods withprobiotics also may help.  

What is a vaginal yeast infection?

A vaginal yeast infection is an infection caused by yeast (a type of fungus). Vaginal yeast infection is sometimes referred to as yeast vaginitis, Candidal vaginitis, or Candidal vulvovaginitis. The scientific name for the yeast that causes vaginitis is Candida. Over 90% of vaginal yeast infections are caused by the species known as Candida albicans. Other Candida species make up the remainder of yeast infections.

Candida species can be present in healthy women in the vagina without causing any symptoms. In fact, it is estimated that 20% to 50% of women have Candidaalready present in the vagina. For an infection to occur, the normal balance of yeast and bacteria is disturbed, allowing overgrowth of the yeast. While yeast can be spread by sexual contact, vaginal yeast infection is not considered to be a sexually-transmitted disease because it can also occur in women who are not sexually active, due to the fact that yeast can be present in the vagina of healthy women.

Vaginal yeast infections are very common, affecting up to 75% of women at some point in life.  

What are the signs and symptoms of a vaginal yeast infection?

Symptoms can include:

• a vaginal discharge that is typically thick,
• odorless, and
• whitish-gray in color.

The discharge has been described as having a cottage-cheese-like consistency.

Other symptoms of a vaginal yeast infection include:

• An intense itching of the vaginal or genital area
• Irritation and burning
• Pain during sexual intercourse
• Pain or burning during urination
• Redness, irritation, or soreness of the vagina or vulva in women; swelling of the vagina

What causes a vaginal yeast infection?

Vaginal yeast infections occur when new yeast is introduced into the vaginal area, or when there is an increase in the quantity of yeast already present in the vagina relative to the quantity of normal bacteria. For example, when the normal, protective bacteria are eradicated by antibiotics (taken to treat a urinary tract, respiratory, or other types of infection) or by immunosuppressive drugs, the yeast can multiply, invade tissues, and cause irritation of the lining of the vagina (vaginitis).

Vaginal yeast infections can also occur as a result of injury to the inner vagina, such as after chemotherapy. Also, women with suppressed immune systems (for example, those taking cortisone-related medications such as prednisone) develop vaginal yeast infections more frequently than women with normal immunity.

Other conditions that may predispose women to developing vaginal yeast infections include

• diabetes,
• pregnancy, and
• taking oral contraceptives.

The use of douches or perfumed vaginal hygiene sprays may also increase a woman's risk of developing a vaginal yeast infection.

A vaginal yeast infection is not considered to be a sexually transmitted disease (STD), since Candida may be present in the normal vagina, and the condition does occur in celibate women.

However, it is possible for men to develop symptoms of skin irritation of the penis from a yeast infection after sexual intercourse with an infected partner, although this is not always the case.

What may increase my risk of getting a vaginal yeast infection?

Women who have conditions that result in decreased immune function are more likely than others to develop yeast infections. These include women withcancer or receiving cancerchemotherapy, those with diabetes, and women taking steroid medications.

Pregnant women and women taking oral contraceptives are also at increased risk.

Taking antibiotics for any reason can alter the normal bacterial populations in the vagina and predispose to the overgrowth of yeast.

Taking steps to reduce moisture in the genital area can reduce the chances of developing a yeast infection. Wearing cotton underwear or underwear with a cotton crotch, wearing loose-fitting pants, and avoiding prolonged wearing of wet workout gear or bathing suits are all measures that can help control moisture, and may help reduce the chance of getting a yeast infection.

Which specialties of doctors treat yeast infections?

Primary care practitioners, including family practice physicians, internists, and pediatricians, may all treat yeast infections. In women, a gynecologist may also treat yeast infections.

How is a vaginal yeast infection diagnosed?

Even though the signs and symptoms of yeast infection may point to the cause,vaginal itching and discharge can be caused by other conditions includingbacterial vaginosis and Trichomonasinfections. To most accurately make the diagnosis, a sample of the discharge is tested in the laboratory, either by culture or by direct examination under a microscope, to identify the yeast organisms and to help rule out other causes such as bacterial vaginosis or sexually-transmitted diseases.

Are there home remedies to treat a vaginal yeast infection?

Yeast infection is treated using antifungal drugs. Both prescription and over-the-counter remedies are available that are effective in treating vaginal yeast infections. Nonprescription drugs are the best home remedy for yeast infections, and they can cure most yeast infections.

What over-the-counter (OTC) medications are available to treat a vaginal yeast infection?

Topical antibiotic (antifungal) treatments (applied directly to the affected area) are available without a prescription. These include vaginal creams, tablets, or suppositories. Regimens vary according to the length of treatment and are typically 1- or 3-day regimens. Recurrent infections may require even longer courses of topical treatment. These topical treatments relieve symptoms and eradicate evidence of the infection in up to 90% of those who complete treatment.

Examples of over-the-counter drugs for yeast infections include:

• clotrimazole (Gyne-Lotrimin, Mycelex)
• miconazole (Micatin, Monistat)
• terconazole (Terzol)

Homeopathic methods have not been adequately studied for clinicians to recommend them and anti –itch medications treat only the itching symptoms but do not treat the underlying cause (yeast infection).

When are oral prescription medications used to treat a vaginal yeast infection?

Oral prescription medications, taken in pill or tablet form, can be used to treat recurrent yeast infections or infections that do not respond to topical treatment.Fluconazole (Diflucan) is typically used as the first-choice oral antifungal medicine.

Fluconazole also may be taken as weekly or monthly maintenance for women who have recurrent yeast infections, but it is first necessary to prove by culture that recurrent infections are occurring.

Oral antifungal medications should not be used by pregnant women.

Oral medications also have more side effects, including

• nausea,
• headache, and
• abdominal pain, than topical medicines.

How can a yeast infection be treated if I am pregnant?

Yeast infections are common during pregnancy. Pregnant women who develop signs of a yeast infection should see a health care professional. He or she can recommend medications and treatments that are safe during pregnancy. Oral antifungal medications are not recommended for use during some states of pregnancy.

Can a man get a yeast infection from his sexual partner?

Most experts do not consider yeast infection to be a sexually-transmitted disease, but cases of irritation and itching of the penis in men have been reported after sexual contact with a woman with a yeast infection, so it is possible for an infected woman to spread the infection to her male sex partner. Treatment of male sexual partners is not considered necessary unless the man develops symptoms.

What are the symptoms of a yeast infection in men?

Symptoms in men may include itching, burning, and pain at the tip of the penis. Discomfort during urination can also occur. The area may appear reddened or irritated. Symptoms may resemble those of other diseases, including some sexually-transmitted infections (STDs), so testing should always be carried out to determine the cause of symptoms in men.

What is the treatment for yeast infection in men?

Treatment for men, like for women, is based upon antifungal medications. These may be applied as topical creams or taken by mouth in pill or tablet form. 

How can vaginal yeast infections be prevented?

Because yeast can be present normally in the vagina of healthy women, not all yeast infections can be prevented. However, it is possible to take preventive measures that may reduce your risk of getting a yeast infection. These include always cleaning the genital area from front to back and changing out of wet bathing suits or damp clothes as soon as possible. Wearing loose-fitting cotton underwear can help reduce moisture and prevent yeast infections. Since chemical irritants can influence the balance of bacteria in the vagina, avoiding products with potential irritants like douches or scented tampons can also help. Regular baths or showers are an adequate way to cleanse the vagina, and douching is not recommended and may actually increase your risk of yeast infection.

Some evidence shows that consumption of foods with probiotics (healthy bacteria that are normally found in the body) like probiotic-containing yogurt may help prevent yeast infections.

What about recurrent yeast infections?

A recurrent yeast infection occurs when a woman has four or more infections in one year that are not related to antibiotic use. Recurrent yeast infections may be related to an underlying medical condition such as impaired immunity and may require more aggressive treatment. This can include longer courses of topical treatments, oral medications, or a combination of the two.

How can you protect yourself from contracting a yeast infection from your sexual partner?

Condoms may help prevent transmission of a yeast infection from women to men, but they are not completely effective since there may be contact with areas of the body not covered by the condom.

Avoiding intercourse when a woman has symptoms of a yeast infection is the best way to prevent spreading of the infection.

Breast Cancer

Breast cancer facts

• Breast cancer is the most common canceramong American women.
• One in every eight women in the United States develops breast cancer.
• There are many types of breast cancer that differ in their capability of spreading (metastasize) to other body tissues.
• The causes of breast cancer are not yet fully known, although a number of risk factors have been identified.
• There are many different types of breast cancer.
• Breast cancer symptoms and signs include
  • a lump in the breast or armpit,
  • bloody nipple discharge,
  • inverted nipple,
  • orange-peel texture or dimpling of the breast's skin,
  • breast pain or sore nipple,
  • swollen lymph nodes in the neck or armpit, and
  • a change in the size or shape of the breast or nipple.
• Breast cancer is diagnosed during a physical exam, by self-examination of the breasts, mammography, ultrasound testing, and biopsy.
• Treatment of breast cancer depends on the type of cancer and its stage (0-IV) and may involve surgery, radiation, or chemotherapy.

According to the American Cancer society

guidelines for mammography differ depending on the organization making recommendations. Currently, the American Cancer Society recommends yearly mammograms for women aged 45-54 for women at average risk for breast cancer and mammograms every two years for women aged 55 and older, who should also have the option to continue yearly screening.

• over 230,000 new cases of invasive breast cancer are diagnosed each year in women and over 2,300 in men;
• approximately 40,000 women and 440 men died of breast cancer in 2015;
• there are over 3.1 million breast cancer survivors in the United States;
• although breast cancer awareness and survival has increased significantly in the United States for all races, several studies have cited a significantly worse survival rate for African-American women compared to white women; and

What is breast cancer?

Breast cancer definition

Breast cancer is a malignant tumor (a collection of cancer cells) arising from the cells of the breast. Although breast cancer predominantly occurs in women, it can also affect men. This article deals with breast cancer in women.

What are the statistics on male breast cancer?

Breast cancer is rare in men (approximately 2,300 new cases diagnosed per year in the U.S.) but typically has a significantly worse outcome. This is partially related to the often late diagnosis of male breast cancer, when the cancer has already spread.

Symptoms are similar to the symptoms in women, with the most common symptom being a lump or change in skin of the breast tissue or nipple discharge. Although it can occur at any age, male breast cancer usually occurs in men over 60 years of age.

What are the different types of breast cancer? Where does breast cancer come from?

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There are many types of breast cancer. Some are more common than others, and there are also combinations of cancers. Some of the most common types of cancer are as follows:

• Ductal carcinoma in situ: The most common type of noninvasive breast cancer is ductal carcinoma in situ (DCIS). This type of cancer has not spread and therefore usually has a very high cure rate.
• Invasive ductal carcinoma: This cancer starts in a duct of the breast and grows into the surrounding tissue. It is the most common form of breast cancer. About 80% of invasive breast cancers are invasive ductal carcinoma.
• Invasive lobular carcinoma: This breast cancer starts in the glands of the breast that produce milk. Approximately 10% of invasive breast cancers are invasive lobular carcinoma.
• The remainder of breast cancers are much less common and include the following:
• Mucinous carcinoma are formed from mucus-producing cancer cells. Mixed tumors contain a variety of cell types. Medullary carcinoma is an infiltrating breast cancer that presents with well-defined boundaries between the cancerous and noncancerous tissue.
• Inflammatory breast cancer: This cancer makes the skin of the breast appear red and feel warm (giving it the appearance of an infection). These changes are due to the blockage of lymph vessels by cancer cells.
• Triple-negative breast cancers: This is a subtype of invasive cancer with cells that lack estrogen and progesterone receptors and have no excess of a specific protein (HER2) on their surface. It tends to appear more often in younger women and African-American women.
• Paget's disease of the nipple: This cancer starts in the ducts of the breast and spreads to the nipple and the area surrounding the nipple. It usually presents with crusting and redness around the nipple.
• Adenoid cystic carcinoma: These cancers have both glandular and cystic features. They tend not to spread aggressively and have a good prognosis.

The following are other uncommon types of breast cancer:

• Papillary carcinoma
• Phyllodes tumor
• Angiosarcoma
• Tubular carcinoma

What causes breast cancer?

There are many risk factors that increase the chance of developing breast cancer. Although we know some of these risk factors, we don't know the cause of breast cancer or how these factors cause the development of a cancer cell.

We know that normal breast cells become cancerous because of mutations in the DNA, and although some of these are inherited, most DNA changes related to breast cells are acquired during one's life.

Proto-oncogenes help cells grow. If these cells mutate, they can increase growth of cells without any control. Such mutations are referred to as oncogenes. Such uncontrolled cell growth can lead to cancer.

What are breast cancer risk factors? How do you get breast cancer?

Some of the breast cancer risk factors can be modified (such as alcohol use) while others cannot be influenced (such as age). It is important to discuss these risks with a health-care provider anytime new therapies are started (for example, postmenopausalhormone therapy).

Several risk factors are inconclusive (such as deodorants), while in other areas, the risk is being even more clearly defined (such as alcohol use).

The following are risk factors for breast cancer:

• Age: The chances of breast cancer increase as one gets older.
• Family history: The risk of breast cancer is higher among women who have relatives with the disease. Having a close relative with the disease (sister, mother, daughter) doubles a woman's risk.
• Personal history: Having been diagnosed with breast cancer in one breast increases the risk of cancer in the other breast or the chance of an additional cancer in the original breast.
• Women diagnosed with certain benign breast conditions have an increased risk of breast cancer. These include atypical hyperplasia, a condition in which there is abnormal proliferation of breast cells but no cancer has developed.
• Menstruation: Women who started their menstrual cycle at a younger age (before 12) or went through menopause later (after 55) have a slightly increased risk.
• Breast tissue: Women with dense breast tissue (as documented by mammogram) have a higher risk of breast cancer.
• Race: White women have a higher risk of developing breast cancer, but African-American women tend to have more aggressive tumors when they do develop breast cancer.
• Exposure to previous chest radiation or use of diethylstilbestrol increases the risk of breast cancer.
• Having no children or the first child after age 30 increases the risk of breast cancer.
• Breastfeeding for one and a half to two years might slightly lower the risk of breast cancer.
• Being overweight or obese increases the risk of breast cancer.
• Use of oral contraceptives in the last 10 years increases the risk of breast cancer.
• Using combined hormone therapy after menopause increases the risk of breast cancer.
• Alcohol use increases the risk of breast cancer, and this seems to be proportional to the amount of alcohol used. A recent study reviewing the research on alcohol use and breast cancer concluded that all levels of alcohol use are associated with an increased risk for breast cancer. This includes even light drinking.
• Exercise seems to lower the risk of breast cancer.
• Genetic risk factors: The most common causes are mutations in the BRCA1 and BRCA2genes (breast cancer genes). Inheriting a mutated gene from a parent means that one has a significantly higher risk of developing breast cancer.

What about antiperspirants or deodorants as causes of breast cancer?

Research has shown that parabens (a preservative used in deodorants) can build up in breast tissues. However, this study did not show that parabens cause breast cancer or that the parabens (which are found in many other products) were linked to the use of deodorants.

A 2002 study did not show any increased risk for breast cancer in women using an underarm deodorant or antiperspirant. A 2003 study showed an earlier age for breast cancer diagnosis in women who shaved their underarms more frequently and used underarm deodorants.

More research is needed to give us the answer about a relationship between breast cancer and underarm deodorants and blade shaving.

Are there any other questions I should ask my doctor about breast cancer?

Yes. There are surely other questions you will wish to ask. Do not hesitate to be very open about your concerns with your doctor. The foregoing questions and comments should demonstrate that the diagnosis and treatment of breast cancer may not be a simple process. Even when all the information is available, there may be difficulties in deciding a proper course of action. However, this decision-making process has a better chance of success when you and the doctor are well-informed and communicating effectively. Although the information here cannot be all-inclusive, we hope it will help you work through this process. 

What tests do physicians use to diagnose breast cancer?

Although breast cancer can be diagnosed by the above signs and symptoms, the use of screening mammography has made it possible to detect many of the cancers early before they cause any symptoms.

The American Cancer Society (ACS) has the following recommendations for breast cancer screenings:

Women should have the opportunity to begin annual screening between 40-44 years of age. Women age 45 and older should have a screening mammogram every year until age 54. Women 55 years of age and older should have biennial screening or have the opportunity to continue screening annually. Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer.

Mammograms are a very good screening tool for breast cancer. As in any test, mammograms have limitations and will miss some cancers. An individual's family history and mammogram and breast exam results should be discussed with a health-care provider.

The ACS does not recommend clinical screening exams in women of any age.

Women at high risk (greater than 20% lifetime risk) should get an MRI and a mammogram every year. Women at moderate risk (15%-20%) should talk to their doctor about the benefits and limitations of adding MRI screening to their yearly mammogram.

What is HER2-positive breast cancer?

For about 20% of women with breast cancer, the cancer cells test positive for HER2. HER2 is a growth-promoting protein located on the surface of some cancer cells. HER2-positive breast cancers tend to grow more rapidly and spread more aggressively.

What tests detect HER2?

All patients with invasive breast cancer should have their tumor cells tested for HER2.

There are four tests for HER2. The interpretation of the tests should be discussed with your health-care team. Either immunohistochemistry (IHC) or in-situ hybridization (ISH) testing may be used.

IHC test: This tests shows if there is too much HER2 protein in the cancer cells and is graded 0 to 3.

FISH test: This test evaluates if there are too many copies of the HER2 gene in the cancer cells. This test is either positive or negative.

SPoT-Light HER2 CISH test: This test also evaluates if there are too many copies of the HER2 gene in the cancer cells and is reported as positive or negative.

Inform HER2 Dual ISH test: This test also evaluates if there are too many copies of the HER2 gene in the cancer cells and is reported as positive or negative.

Do symptoms and signs of HER2-positive breast cancer differ from those of HER2-negative breast cancer?

The signs and symptoms for HER2-positive breast cancers are the same as for HER2-negative breast cancers, except for the fact that HER2-positive cancers grow faster and are more likely to spread.

What are therapies for HER2-positive breast cancers?

All therapy needs to be evaluated by your health-care team and guided in response to all test results available and the specific circumstances of your cancer.

There are targeted therapies for HER2-positive breast cancers; a number of drugs are available to target this protein:

• Trastuzumab (Herceptin): a monoclonal antibody given by itself or with chemotherapy to treat HER2-positive breast cancers
• Pertuzumab (Perjeta): another monoclonal antibody that targets HER2-positive cancers
• Ado-trastuzumab emtansine or TDM-1 (Kadcyla): a monoclonal antibody that is attached to a chemotherapy drug
• Lapatinib (Tykerb): a kinase inhibitor usually used in adjunct with chemotherapy or hormone therapy

How are breast cancer stages determined?

Staging is the process of determining the extent of the cancer and its spread in the body. Together with the type of cancer, staging is used to determine the appropriate therapy and to predict chances for survival.

To determine if the cancer has spread, several different imaging techniques can be used.

• Computerized tomography (CT scan): These specialized X-rays are used to look at different parts of your body to determine if the breast cancer has spread. It could include a CT of the brain, lungs, or any other area of concern.
• Chest X-ray: It looks for spread of the cancer to the lung.
• Mammograms: More detailed and additional mammograms provide more images of the breast and may locate other abnormalities.
• Bone scan: A bone scan determines if the cancer has spread (metastasized) to the bones. Low level radioactive material is injected into the bloodstream, and over a few hours, images are taken to determine if there is uptake in certain bone areas, indicating metastasis.
• Positron emission tomography (PET scan): A radioactive material is injected that is absorbed preferentially by rapidly growing cells (such as cancer cells). The PET scanner then locates these areas in your body.

Staging system

This system is used by a health-care team to summarize in a standard way the extent and spread of the cancer. This staging can then be used to determine the treatment most appropriate for the type of cancer.

The most widely used system in the U.S. is the American Joint Committee on Cancer TNM system.

Besides the information gained from the imaging tests, this system also uses the results from surgical procedures. After surgery, a pathologist looks at the cells from the breast cancer as well as from the lymph nodes. This information gained is incorporated into the staging as it tends to be more accurate than the physical exam and X-ray findings alone.

TNM staging. This system uses letters and numbers to describe certain tumor characteristics in a uniform manner. This allows health-care providers to stage the cancer (which helps determine the most appropriate therapy) and aids communication among health-care providers.

T: describes the size of the tumor. It is followed by a number from 0 to 4. Higher numbers indicate a larger tumor or greater spread:

• TX: Primary tumor cannot be assessed
• T0: No evidence of primary tumor
• Tis: Carcinoma in situ
• T1: Tumor is 2 cm or less across
• T2: Tumor is 2 cm-5 cm
• T3: Tumor is more than 5 cm
• T4: Tumor of any size growing into the chest wall or skin.

N: describes the spread to lymph node near the breast. It is followed by a number from 0 to 3.

• NX: Nearby lymph nodes cannot be assessed (for example if they have previously been removed).
• N0: There has been no spread to nearby lymph nodes. In addition to the numbers, this part of the staging is modified by the designation "i+" if the cancer cells are only seen by immunohistochemistry (a special stain) and "mol+" if the cancer could only be found using PCR (special detection technique to detect cancer at the molecular level).
• N1: Cancer has spread to one to three axillary lymph nodes (underarm lymph nodes) or tiny amounts of cancer are found in internal mammary lymph nodes (lymph nodes near breastbone).
• N2: Cancer has spread to four to nine axillary lymph nodes or the cancer has enlarged the internal mammary lymph nodes.
• N3: Any of the conditions below
  • Cancer has spread to 10 or more axillary lymph nodes with at least one cancer spread larger than 2 mm.
  • Cancer has spread to lymph nodes under the clavicle with at least area of cancer spread greater than 2 mm.

M: This letter is followed by a 0 or 1, indicating whether the cancer has spread to other organs.

• MX: Metastasis cannot be assessed.
• M0: No distant spread is found on imaging procedures or by physical exam.
• M1: Spread to other organs is present.

Once the T, N, and M categories have been determined, they are combined into staging groups. There are five major staging groups, stage 0 to stage IV, which are subdivided into A and B, or A and B and C, depending on the underlying cancer and the T, N, and M scale.

Cancers with similar stages often require similar treatments.

What are breast cancer treatments?

Patients with breast cancer have many treatment options. Most treatments are adjusted specifically to the type of cancer and the staging group. Treatment options should be discussed with a health-care team. The following are the basic treatment modalities used in the treatment of breast cancer.

Surgery

Most women with breast cancer will require surgery. Broadly, the surgical therapies for breast cancer can be divided into breast-conserving surgery and mastectomy.

Breast-conserving surgery

This surgery will only remove part of the breast (sometimes referred to as partial mastectomy). The extent of the surgery is determined by the size and location of the tumor.

In a lumpectomy, only the breast lump and some surrounding tissue is removed. The surrounding tissue (surgical margins) are inspected for cancer cells. If no cancer cells are found, this is called "negative" or "clear margins." Frequently, radiation therapy is given after lumpectomies.

Mastectomy

During a mastectomy (sometimes also referred to as a simple mastectomy), all the breast tissue is removed. If immediate reconstruction is considered, a skin-sparing mastectomy is sometimes performed. In this surgery, all the breast tissue is removed as well, but the overlying skin is preserved.

Radical mastectomy

During this surgery, the surgeon removes the axillary lymph nodes as well as the chest wall muscle in addition to the breast. This procedure is done much less frequently than in the past, as in most cases, a modified radical mastectomy is as effective.

Modified radical mastectomy

This surgery removes the axillary lymph nodes in addition to the breast tissue. Depending on the stage of the cancer, a health-care team might give someone a choice between a lumpectomy and a mastectomy. Lumpectomy allows sparing of the breast but usually requires radiation therapy afterward. If lumpectomy is indicated, long-term follow-up shows no advantage of a mastectomy over the lumpectomy.

Preventive surgery

For a small group of patients who have a very high risk of breast cancer, surgery to remove the breasts may be an option. Although this reduces the risk significantly, a small chance of developing cancer remains.

Double mastectomy is a surgical option to prevent breast cancer. This prophylactic (preventive) surgery can decrease the risk of breast cancer by about 90% for women at moderate to high risk for breast cancer.

Such an approach should be carefully discussed with a health-care team.

The discussion about whether to undergo any preventive surgery should include

• genetic testing for BRCA1 or BRCA2 gene mutations,
• full review of risk factors,
• family history of cancer and specifically breast cancer, and
• other preventive options such as medications.

Radiation therapy

Radiation therapy destroys cancer cells with high energy rays. There are two ways to administer radiation therapy.

External beam radiation

This is the usual way radiation therapy is given for breast cancer. A beam of radiation is focused onto the affected area by an external machine. The extent of the treatment is determined by a health-care team and is based on the surgical procedure performed and whether lymph nodes were affected or not.

The local area will usually be marked after the radiation team has determined the exact location for the treatments. Usually, the treatment is given five days a week for five to six weeks.

Brachytherapy

This form of delivering radiation uses radioactive seeds or pellets. Instead of a beam from the outside delivering the radiation, these seeds are implanted into the breast next to the cancer.

Chemotherapy

Chemotherapy is treatment of cancers with medications that travel through the bloodstream to the cancer cells. These medications are given either by intravenous injection or by mouth.

Chemotherapy can have different indications and may be performed in different settings as follows:

• Adjuvant chemotherapy: If surgery has removed all the visible cancer, there is still the possibility that cancer cells have broken off or are left behind. If chemotherapy is given to assure that these small amounts of cells are killed as well, it is called adjunct chemotherapy. Chemotherapy is not given in all cases, since some women have a very low risk of recurrence even without chemotherapy, depending upon the tumor type and characteristics.
• Neoadjuvant chemotherapy: If chemotherapy is given before surgery, it is referred to as neoadjuvant chemotherapy. Although there seems to be no advantage to long-term survival whether the therapy is given before or after surgery, there are advantages to see if the cancer responds to the therapy and by shrinking the cancer before surgical removal.
• Chemotherapy for advanced cancer: If the cancer has metastasized to distant sites in the body, chemotherapy can be used for treatment. In this case, the health-care team will need to determine the most appropriate length of treatment.

There are many different chemotherapeutic agents that are either given alone or in combination. Usually, these drugs are given in cycles with certain treatment intervals followed by a rest period. The cycle length and rest intervals differ from drug to drug.

Hormone therapy

This therapy is often used to help reduce the risk of cancer reoccurrence after surgery, but it can also be used as adjunct treatment.

Estrogen (a hormone produced by the ovaries) promotes the growth of a few breast cancers, specifically those containing receptors for estrogen (ER positive) or progesterone (PR positive). The following drugs are used in hormone therapy:

• Tamoxifen (Nolvadex): This drug prevents estrogen from binding to estrogen receptors on breast cells.
• Toremifene (Fareston) works similar to Tamoxifen and is only indicated in metastatic breast cancer.
• Fulvestrant (Faslodex): This drug eliminates the estrogen receptor and can be used even if tamoxifen is no longer useful.
• Aromatase inhibitors: They stop estrogen production in postmenopausal women. Examples areletrozole (Femara), anastrozole (Arimidex), and exemestane (Aromasin).

Targeted therapy

As we are learning more about gene changes and their involvement in causing cancer, drugs are being developed that specifically target the cancer cells. They tend to have fewer side effects than chemotherapy (as they target only the cancer cells) but usually are still used in adjunct with chemotherapy.

Alternative treatments

Whenever a disease has the potential for much harm and death, physicians search for alternative treatments. As a patient or the loved one of a patient, there may be an inclination to try everything and leave no option unexplored. The danger in this approach is usually found in the fact that the patient might not avail themselves of existing, proven therapies. One should discuss any interest in alternative treatments with a health-care team and together explore the different options.

What are breast cancer survival rates by stage? What is the prognosis of breast cancer?

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Survival rates are a way for health-care professionals to discuss the prognosis and outlook of a cancer diagnosis with their patients. Patients have to determine if they want to know this number or not and should let their health-care providers know.

The number most frequently discussed is five-year survival. It is the percentage of patients who live at least five years after they are diagnosed with cancer. Many of these patients live much longer, and some patients die earlier from causes other than breast cancer. With a constant change in therapies, these numbers also change. The current five-year survival statistic is based on patients who were diagnosed at least five years ago and may have received different therapies than are available today.

All of this needs to be taken into consideration when interpreting these numbers for oneself.

Below are the statistics from the National Cancer Institute's SEER database.

Stage	Five-year survival rate
0	100%
I	100%
II	93%
III	72%
IV	22%

These statistics are for all patients diagnosed and reported. Several recent studies have looked at different racial survival statistics and have found a higher mortality (death rate) in African-American women compared to white women in the same geographic area. Continue Reading

Is it possible to prevent breast cancer?

There is no guaranteed way to prevent breast cancer. Reviewing the risk factors and modifying the ones that can be altered (increase exercise, keep a good body weight, etc.) can help in decreasing the risk.

Following the American Cancer Society's guidelines for early detection can help early detection and treatment.

There are some subgroups of women that should consider additional preventive measures.

Women with a strong family history of breast cancer should be evaluated by genetic testing. This should be discussed with a health-care provider and be preceded by a meeting with a genetic counselor who can explain what the testing can and cannot tell and then help interpret the results after testing.

Chemoprevention is the use of medications to reduce the risk of cancer. The two currently approved drugs for chemoprevention of breast cancer are tamoxifen (a medication that blocks estrogen effects on the breast tissue) and raloxifene (Evista), which also blocks the effect of estrogen on breast tissues. Their side effects and whether these medications are right for an individual need to be discussed with a health-care provider.

Aromatase inhibitors are medications that block the production of small amounts of estrogen usually produced in postmenopausal women. They are being used to prevent reoccurrence of breast cancer but are not approved at this time for breast cancer chemoprevention.

For a small group of patients who have a very high risk of breast cancer, surgery to remove the breasts may be an option. Although this reduces the risk significantly, a small chance of developing cancer remains.

What research is being done on breast cancer? Is it worthwhile to participate in a breast cancer clinical trial?

Without research and clinical trials, there would be no progress in our treatment of cancers.

Research can take many forms, including research directly on cancer cells or using animals.

Research that a patient can be involved in is referred to as a clinical trial. In clinical trials, different treatment regimens are compared for side effects and outcomes, including long-term survival. Clinical trials are designed to find out whether new approaches are safe and effective.

Whether one should participate in a clinical trial is a personal decision and should be based upon a full understanding of the advantages and disadvantages of the trial. One should discuss the trial with a health-care team and ask how this trial might be different from the treatment one would usually receive.

Someone should never be forced to participate in a clinical trial or be involved in a trial without full understanding of the trial and a written and signed consent. 

I may have breast cancer. What questions should I ask my doctor?

If you have received a positive or possible diagnosis of breast cancer, there are a number of questions that you can ask your doctor. The answers you receive to these questions should give you a better understanding of your specific diagnosis and the corresponding treatment. It is usually helpful to write your questions down before you meet with your health-care provider. This gives you the opportunity to ask all your questions in an organized fashion.

Each question is followed by a brief explanation as to why that particular question is important. We will not attempt to answer these questions in detail here because each individual case is just that, individual. This outline is designed to provide a framework to help you and your family make certain that most of the important questions in breast cancer diagnosis and treatment have been addressed. As cancer treatments are constantly evolving, specific recommendations and treatments might change and you should always confer with your treatment team regarding any questions. You obviously should add your own questions and concerns to these when you have a discussion with your doctor.

Is the doctor sure I have breast cancer?

Certain types of cancer are relatively easy to identify by standard microscopic evaluation of the tissue. This is generally true for the most common types of breast cancer. This obviously implies that you have had a biopsy (removal of some tissue at the possible cancer site) that was then reviewed by a pathologist.

However, as the search for earlier and rarer forms of breast cancer progresses, it can be difficult to be certain that a particular group of cells is malignant (cancerous). At the same time, benign conditions may have cells that are somewhat distorted in appearance or pattern of growth (known as atypical cells or atypical hyperplasia). For this reason, it is important that the pathologist reading the slides of your breast biopsy be experienced in breast pathology. Most good pathology groups have multiple pathologists review questionable or troublesome slides. In more difficult cases, the slides will often be sent to recognized specialists with considerable expertise in breast pathology. 

What type of breast cancer do I have?

Breast cancer is not a single disease. There are many types of breast cancer, and they may have vastly different implications. Breast cancers range from localized cancers such as ductal carcinoma in situ (DCIS) to invasive cancers that can rapidly spread (metastasize). In the middle of the spectrum are breast cancers, such as colloid carcinomas and papillary carcinomas, which have a much more favorable outlook (prognosis) than the other more typically invasive breast cancers. Sometimes, noninvasive DCIS is found around invasive breast cancers.

The treatment team should be able to explain what type of cancer you have, how they determined this, and the treatment they recommend.

What difference does a precise breast cancer diagnosis make?

The importance of an accurate diagnosis cannot be overstated. It is the precise diagnosis that determines the recommended treatment. Treatment must be specifically tailored to the specific type of breast cancer as well as to the individual patient.

A doctor should be able to give someone a clear description of the type of breast cancer along with the treatment options that are appropriate to one's case.

What has been done to exclude cancer in other areas of the same breast or in my other breast?

Unfortunately, there are some patients who may have more than one area of malignancy in the same breast or even an additional malignancy in the other breast. If this does occur, it can greatly change the recommendations for treatment.

Therefore, it is critically important that your doctors carefully investigate beyond the immediate site of the tumor to make certain there are no other areas with possible malignancy.

Sometimes discovering these "secondary" areas requires careful review of your mammograms. It may also require the addition of special views from different angles and specialized examination of your breasts by ultrasound, MRI, or other imaging techniques. Sometimes imaging techniques will be used to evaluate the rest of your body, as well.

What type of medical team do I need for the most accurate breast cancer diagnosis?

A well-coordinated team, which includes input from the pathologist, surgeon, and radiologist, is usually the best way to approach treatment decisions. Advice from the entire team must be available during biopsies and any tumor-clearing surgery to ensure the best chance of a favorable outcome for the patient.

How important is the role of the pathologist reading my slides?

The pathologist evaluating the slides made from fine-needle aspiration biopsies, core biopsies, and tissue slides of the breast must have a great deal of experience and special training. It is important that the pathologist reliably determine the presence or absence of cancer and distinguish cancer from other conditions such as hyperplasia with atypia (an overgrowth with unusual-looking but benign cells). The pathologist also orders and interprets special studies (see below) on your cancer tissue to determine the precise characteristics of the cancer cells, such as whether the cancer expresses hormone receptors. These results are used to further specify the type of breast cancer and optimize treatment decisions. The remainder of the treatment will be based on the pathologist's diagnosis.

Have my slides been reviewed by more than one pathologist?

A review by more than one pathologist is optimal. There are many subtleties that can be overlooked when reviewing microscope slides. These can lead to both over-reading (making a false-positive diagnosis) and under-reading (making a false-negative diagnosis). When slides are read a second time by another pathologist followed by a discussion of the conclusions, most diagnostic problems are resolved.

There are almost always several pathologists available who can review the pathology of your slides (this is termed a "double reading"). The added safeguard of double reading may not be necessary in most cases of breast cancers but can be a critical factor in some cases.

Can I have my biopsy reviewed by a pathologist at another diagnostic center?

It should always be possible to send slides from your biopsy to a pathologist at another diagnostic center. First of all, there should not be a rush to treatment; breast cancer is almost never an emergency. Developing the best treatment plan depends on a good, thorough pathologic evaluation as well as a complete workup of both breasts, as noted above. You should discuss this with your treatment team or primary-care giver as they can help you arrange for this.

Second, good pathologists are never offended by a request for an outside opinion. They also usually know the names of some of the finest breast pathologists in the country and should be willing to arrange a consultation with one of these doctors.

In most cases of breast cancer, it is not necessary to obtain this in-depth consultation. However, if there are any unusual aspects of your case, it can be important in your decision-making process. The matter of obtaining additional consults may take a week or more.