Breast Cancer: Breast Self-Exam

If you've been treated for breast cancer, you should continue to practice breast self-examination, checking both the treated area and your other breast each month. You should report any changes to your doctor right away. Breast changes that might indicate a recurrence include:

• An area that is distinctly different from any other area on either breast
• Lump or thickening in or near the breast or in the underarm that persists through the menstrual cycle
• A change in the size, shape, or contour of the breast
• A mass or lump, which may feel as small as a pea
• A marble-like area under the skin
• A change in the feel or appearance of the skin on the breast or nipple, including skin that is dimpled, puckered, scaly, or inflamed (red, warm or swollen)
• Bloody or clear fluid discharge from the nipples
• Redness of the skin on the breast or nipple

In addition to performing monthly breast self-exams, keep your scheduled follow-up appointments with your healthcare provider. During these appointments, your healthcare provider will perform a breast exam, order lab or imaging tests as needed, and ask you about any symptoms you might have. Initially, these follow-up appointments may be scheduled every three to four months. The longer you are cancer-free, the less often you will need to see your healthcare provider. Continue to follow your healthcare provider's recommendations on screening mammograms (usually recommended once a year).

Prognostic indicators are characteristics of a patient and her tumor that may help a physician predict a cancer recurrence. These are some common indicators:

• Lymph node involvement. Women who have lymph node involvement are more likely to have a recurrence.
• Tumor size. In general, the larger the tumor, the greater the chance of recurrence.
• Hormone receptors. About two-thirds of all breast cancers contain significant levels of estrogen receptors, which means the tumors are estrogen receptor positive (ER+). ER-positive tumors tend to grow less aggressively and may respond favorably to treatment with hormones.
• Histologic grade. This term refers to how much the tumor cells resemble normal cells when viewed under the microscope; the grading scale is 1 to 4. Grade 4 tumors contain very abnormal and rapidly growing cancer cells. The higher the histologic grade, the greater chance of recurrence.
• Nuclear grade. This is the rate at which cancer cells in the tumor divide to form more cells. Cancer cells with a high nuclear grade (also called proliferative capacity) are usually more aggressive (faster growing).
• Oncogene expression. An oncogene is a gene that causes or promotes cancerous changes within the cell. Tumors that contain certain oncogenes may increase a patient's chance of recurrence.

Following surgery or radiation, your treatment team will determine the likelihood that the cancer will recur outside the breast. This team usually includes a medical oncologist, a specialist trained in using medicines to treat breast cancer. The medical oncologist, who works with your surgeon, may advise the use of tamoxifen (tamoxifen citrate, Nolvadex) or possibly chemotherapy. These treatments are used in addition to, but not in place of, local breast cancer treatment with surgery and/or radiation therapy.

The type of treatment for local breast cancer recurrences depends on your initial treatment. If you had a lumpectomy, local recurrence is usually treated with mastectomy, since radiation therapy cannot be delivered twice to the same area. If the initial treatment was mastectomy, recurrence near the mastectomy site is treated by removing the tumor whenever possible, usually followed by radiation therapy.

In either case, hormone therapy and/or chemotherapy may be used after surgery and/or radiation therapy. If breast cancer is found in the other breast, it may be a new tumor unrelated to the first breast cancer. Treatment would include a lumpectomy or mastectomy and possibly systemic therapy (chemotherapy and/or hormonal therapy).

Women with distant recurrence involving organs such as the bones, lungs, brain, or other organs are treated with systemic therapy. Radiation therapy or surgery may also be recommended to relieve certain symptoms.

Immunotherapy with trastuzumab (Herceptin) alone or with chemotherapy may be recommended for women whose cancer cells have high levels of the HER2/neu protein. Immunotherapy is generally started after hormonal or chemotherapy are no longer effective.