Treating breast cancer has three aims:

• To remove the primary tumor.
• To reduce the chance that the cancer will return in the breast or the armpit.
• To reduce the chance that cancer will establish secondaries elsewhere in the body (distant spread).

Local treatment consists of surgery and radiotherapy. It is aimed at the lump and the lymph nodes in the armpit. Treatment additional to surgery is called adjuvant therapy, and consists of combinations of radiotherapy, chemotherapy and hormone therapy. Chemotherapy and hormone therapy are also called systemic treatment because they affect the whole body, and not just the local area.

The treatment you receive will depend on your diagnosis. You may be offered a choice of operations, a combination of surgery and radiotherapy, or a combination of surgery and systemic treatments.

For women with early invasive breast cancer, the survival rate has been shown to be the same with either breast conservation or modified radical mastectomy. Breast conservation, which consists of lumpectomy (removal of the lump only), axillary node clearance and radiotherapy, can be considered whatever your age. But it is not suitable for women who choose not to have radiotherapy or who prefer to have the whole breast removed for peace of mind.

Most treatments for advanced cancer involving the skin and muscles of the armpit, with or without metastatic spread, include systemic therapy. For pre-menopausal women, this is usually chemotherapy and for older women, it is commonly hormone therapy.

Treating breast cancer

• Treatment is aimed at the breast lump, the lymph nodes and distant disease.
• Treatment can be any combination of surgery, radiotherapy, chemotherapy or hormone therapy.

Before you proceed with your treatment..

When evaluating different treatments, the best treatment for your cancer should always be your first concern. Before choosing your treatment, consider the following:

• Be an informed patient - Learn all you can about your type of breast cancer and your treatment options. Do your own research and ask your doctor any questions you may have regarding your options.
• Get a second option - It’s quite a common practice to seek a second, or even third, opinion from other specialists before proceeding with treatment.

Factors that affect treatment decisions and prognosis. A number of factors are used to predict the outlook of successful treatment and the possibility for a cure. They include the following:

Lymph node status

If the cancer is ductal carcinoma in situ (DCIS) or has not spread to the lymph nodes (that is, node-negative), the five-year survival rates with treatment are up to 98%.

It should be noted, however, that the cancer recurs in between 9% and 30% of such node-negative cancers. Recurrence is a potentially life-threatening problem, even if the disease relapses locally in the same breast. Nevertheless, in one study, among DCIS patients with locally invasive recurrence eight-year mortality rates were still only 12%.

If the lymph nodes contain cancer cells (that is, are node positive), then survival rates fall. If the tumor is larger than 5 cm or there is widespread involvement in the lymph nodes, it is sometimes referred to as locally advanced. In such cases, the survival rate drops to about 75% and below.

Tumor size, grade and type

The location of the tumor within the breast is an important prognostic factor. Tumors that develop toward the outside of the breast tend to be less serious than those that occur more toward the middle of the breast.

Large tumors pose a higher risk than small tumors. Undifferentiated tumors, which have indistinct margins, are more dangerous than those with well-defined margins.

Hormone receptors

Breast cancer cells may contain receptors, or binding sites, for hormones like estrogen or progesterone. Cells containing these binding sites are known as hormone receptor-positive cells and if they lack them are called hormone receptor-negative cells.

Hormone receptor-positive cells grow more slowly than receptor negative cells. Women have a better prognosis if their tumors are receptor-positive because these cells grow more slowly than receptor-negative cells and they have more treatment options. (Hormone receptor-negative tumors can only be treated with chemotherapy.)

HER-2

Researchers are investigating a number of substances in the tumor cells that will indicate whether a cancer is likely to spread or not. Such chemical markers may help physicians determine treatments, and some may even prove to be targets for future drugs.

One of such markers is the HER-2 protein. This protein is part of the epidermal growth factor receptor family and is becoming an important marker in breast cancer. It is involved in the growth and spread of breast cancer cells, and about 25% to 30% of breast cancer patients have high levels of this protein. The presence of HER-2 may suggest aggressive cancer and is proving to be important in determining treatment choices.

Influence of genes

Determining a "genetic signature" for a tumor may prove to be a very powerful predictor of the aggressive nature of a breast cancer. Researchers have focused on 70 genes whose activity patterns may help make such predictions.

The relevance of the inherited BRCA1 or BRCA2 mutations to survival is controversial. Some studies have suggested that these mutations offer a survival advantage, while others suggest that they make no difference or even worsen prognosis. Women with these genetic mutations do have a greater risk for a new cancer to develop. Patients with BRCA1 mutations tend to develop tumors that are hormone receptor negative, which can behave more aggressively.

Proliferation rate

The more rapidly a tumor grows, the more dangerous it is. A number of tests measure aspects of cancer cell division and may eventually prove to predict the disease. For example, the mitotic index (MI) is a measurement of the rate at which cells divide. The higher the MI, the more aggressive the cancer. Another measures cells at a certain phase of their division.

Tests for metasteses If the cancer has metastasized and spread through the blood stream to other sites (most often the lung, liver and bone), the average survival time for patients treated with chemotherapy is between one and two years (with some patients living for many years). However, there is more hope now and in the future as new combinations of drugs are improving these averages.

Surgery is a local treatment with the primarily aim of removing as much cancerous tissue as possible from the breast. It is usually the first line of treatment for breast cancer and most women will have at least one operation during the course of their disease. Studies have shown that breast conserving therapy and mastectomy are equal in terms of their effectiveness.

Breast conserving surgery (lumpectomy)

Breast conserving surgery involves surgical removal of only the cancerous area of the breast and some surrounding normal tissue. Usually, underarm lymph nodes are also removed. This procedure is often called a lumpectomy.

Studies have shown that for smaller tumors, a less extensive operation that removes the tumor but leaves most of the remaining breast tissue intact is as effective as removing the entire breast.

Although there is a chance that not all the cancer will be removed, the breast is saved, the surgery is less invasive and an overnight stay in the hospital may not be required. Radiation therapy is generally required to decrease the chances of recurrence.

Side effects may include temporary loss of arm movement, numbness and lymphedema, a fluid build-up that causes swelling in the arm and hand on the surgery side.

Mastectomy

Surgery of any kind can be a challenging experience, but mastectomy — the surgical removal of one or both breasts — may raise special concerns. You may wonder if this surgery is your best option for treating or preventing breast cancer. You may also be concerned about how you'll feel and look after the mastectomy.

Mastectomy involves surgical removal of the entire breast and usually some underarm lymph nodes. Mastectomy is an invasive procedure, requiring a short stay of between five and 10 days in the hospital. Side effects may include temporary soreness, loss of arm movement, numbness and lymphedema

Before deciding on surgery, make sure you know all the facts. Take your time to gather information on the procedure and what you can expect before and after the surgery. Talk with your doctor for all the information you need before making your decision.

Radiation therapy is often not required and there are several options for reconstruction if a woman chooses. However, there is a small chance that not all the cancer will be removed with a mastectomy.

Who should undergo a mastectomy?

Mastectomy is an effective treatment for breast cancer. It may be recommended over other treatment options – such as radiation therapy and a lumpectomy (surgery to remove the tumor instead of the whole breast) if:

• You're in the first or second trimester of pregnancy, when radiation creates an unacceptable risk to your unborn child.
• You have two or more tumors in separate areas of the breast.
• You have widespread or malignant-appearing microcalcifications throughout the breast.
• You've previously had radiation treatment to the breast region.
• You have a strong family history of breast cancer.
• You carry a gene mutation that carries a high risk of developing another breast cancer.

This will only be done if the other types of biopsy cannot be used, or do not give a definite result. Surgical biopsy means using a surgical knife (scalpel) to open the area and remove a tissue sample from the lump. Or, if the lump is small enough, the whole of it may be removed.

Depending on the scale of the biopsy operation, you may have this done under local or general anaesthetic. If the lump turns out to be benign, you may not have any more treatment. If it is cancer, your doctor will talk over the treatment options with you.

Surgical biopsy procedures include the following:

Excisional biopsy

This procedure can be performed whether or not the breast mass is palpable and is usually performed under local anesthesia (i.e., the patient remains awake during the procedure) on an outpatient basis. The area is numbed with a local anesthetic and a sedative is usually administered. A small incision of about 1 to 2 inches is made as close to the lump as possible. The surgeon removes a piece of tissue, or if it is small, the entire lump and the incision is sutured. The biopsy usually takes about an hour to perform. Postoperative pain is usually minimal and resolves within a few days.

If the lump cannot be felt, the procedure is slightly more involved and time consuming. Because it cannot be felt, it must be located by a process called needle localization. A mammogram or ultrasound is used to pinpoint the lump. A wire needle is inserted into the breast, marking the location of the lump. The wire is left inside the breast and taped to the skin, and the patient is taken to the operating room to have the biopsy.

Although the main purpose of an excisional biopsy is to diagnose cancer, the procedure can also be considered treatment if the surgeon finds the tumor and completely removes it. Excisional biopsy may be the only surgical treatment a woman needs to have a cancerous tumor removed from her breast. For other women, the removal of some lymph nodes may be necessary.

Advantages

• The procedure is generally very accurate and produces very few false negative results. A false negative result is one that says cancer is not present when in fact it is.
• An excisional biopsy provides complete information about the abnormality, such as the tumor’s size, type, grade and hormone receptor status. Such information is useful in planning a patient’s treatment.
• Excisional biopsy also doubles as a treatment for breast cancer as it may be the only surgery a patient needs for removing the tumor.

Disadvantages

• Excisional biopsy is expensive, has a more uncomfortable and longer recovery period and increases the risk of infection and bruising.
• The amount of tissue removed can also affect the look and feel of the breast. If a very large lump was removed, the scar may be large and may leave an indentation in the breast.
• Finally, if a woman chooses excisional biopsy as her first biopsy choice and the biopsy results are benign, she may have had more extensive surgery than necessary.

Incisional biopsy

In an incisional biopsy, only a portion of a lump or suspicious area is removed for diagnosis. The tissue is then examined under a microscope. This procedure is done most often on women with larger cancerous tumors too large to be removed with an excisional biopsy. The amount of tissue removed during incisional biopsy is enough to provide detailed information that can help a woman and her physician plan her treatment.

Most women undergoing biopsy will know beforehand which biopsy they will be getting. In some cases, though, when a surgeon finds that a tumor is too extensive to totally remove, an incisional biopsy will be performed to remove only part of the tumor.

In general, this procedure is similar to that for an excisional biopsy, but only less tissue is removed.

Advantages

• Incisional biopsy is highly accurate, producing very few false negative results. A false negative result is one that says cancer is not present when in fact it is.
• An incisional biopsy also provides a greater amount of information such as the tumor’s type, grade and hormone receptor status to help in a patient’s treatment plan.

Disadvantages

• Incisional biopsy is expensive, has a more uncomfortable recovery period and increases the risk of infection and bruising.
• The amount of tissue removed can also change the look and feel of the breast.
• Incisional biopsy only removes part of the tumor rather than all of it, as in excisional biopsy. This means that additional surgery may still be necessary to treat the cancer.

Used after local treatment to kill any cancer cells that may have spread from the breast to other parts of a woman’s body, adjuvant therapy includes chemotherapy, hormone therapy and biological therapy. Chemotherapy and hormone therapy are both also systemic treatment as they affect the entire body.

As with most aspects of a disease as complex as breast cancer, there is no simple answer as to who should have adjuvant treatment. When deciding whether to give it or not, doctors will try to predict the likelihood that the patient’s tumor will recur.

Chemotherapy

Chemotherapy involves using drugs to kill cancer cells that may be in a woman’s body. The treatment is given one or two times a month for 3 to 6 months. Years of testing and research have proved chemotherapy to be an effective cancer treatment. It may be the only treatment required, or it may be used in combination with other treatments, such as surgery and radiation therapy.

Chemotherapy works by killing rapidly dividing cells. These cells include cancer cells, which continuously divide to form more cells, and healthy cells that divide quickly, such as those in your bone marrow, gastrointestinal tract, reproductive system and hair follicles. Healthy cells usually recover shortly after chemotherapy is complete.

Side effects can include hair loss, nausea, dry mouth, nausea, fatigue, loss of appetite and liver damage for a short period of time. Long-term side effects, although rare, may include organ damage, nerve damage, and blood in urine or other cancers such as Hodgkin’s disease.

What’s the purpose of chemotherapy?

Chemotherapy can serve varying goals. One of chemotherapy's main advantages is that, unlike radiation which treats only the area of the body exposed to the radiation, chemotherapy treats the entire body. As a result, any cells that may have escaped from the original cancer are treated.

Depending on what type of cancer you have and whether it has spread, your doctor may use chemotherapy to:

• Eliminate all cancer cells in your body, even when cancer is widespread.
• Prolong your life by controlling cancer growth and spread.
• Relieve symptoms and enhance your quality of life.

Hormone therapy

There are certain hormones that can attach to cancer cells and can affect their ability to multiply. Hormone therapy involves using drugs to prevent your body’s hormones, especially estrogen, from promoting the growth of any cancer cells that may remain after surgery. The therapy may involve taking a drug, such as tamoxifen, for several years, or it may involve other drugs to decrease the body’s production of estrogen.

With breast cancer, the female hormones estrogen and progesterone can promote the growth of some breast cancer cells. So in these patients, hormone therapy is given to block the body's naturally occurring estrogen and fight the cancer's growth. Side effects may include hot flashes, vaginal dryness, weight gain and depression, and depending on the drugs used, the risks may differ from one to another.

There are two types of hormone therapy for breast cancer:

• Drugs that inhibit estrogen and progesterone from promoting breast cancer cell growth.
• Drugs or surgery to turn off the production of hormones from the ovaries.

Who gets treated with hormone therapy?

As part of the diagnosis process, tests are done to determine if the cancer cells have estrogen or progesterone receptors. If so, that means that growth of the cancer can be stimulated with these hormones. If a cancer is found to have these receptors, hormone therapy is recommended as part of the treatment plan.

Biological therapy

Biological therapy involves using the body’s immune system to fight cancer and reduce the side effects that are caused by other treatments. Biological therapy is sometimes called biological response modifier therapy or immunotherapy.

Although biological therapy and chemotherapy are may seem alike, they work in different ways. Biological therapy helps the immune system fight cancer, while chemotherapy attacks the cancer cells directly.

Doctors are not sure how biological therapy can help the immune system fight cancer, but they think it may:

• Stop or slow the growth of cancer cells.
• Make it easier for your immune system to destroy, or get rid of, cancer cells.
• Keep cancer from spreading to other parts of your body.

Biological therapy is relatively new and many are still being studied in clinical trials.

Radiation therapy

Radiation therapy involves using high energy X-rays to destroy cancer cells in the breast, chest and axillary lymph nodes. Treatment is given regularly over a period of time to have the greatest effect on the cancer cells while limiting the damage to normal cells.

It is most often used with breast conserving surgery, but may also be recommended after a mastectomy for women with four or more positive lymph nodes or women with breast cancers over 5 cm in size or those with close or positive margins (cancer cells close to or at the edge of the surgically removed breast.)

Side effects may include fatigue, soreness and swelling in the breast area and lymphedema that may develop later. It is a local treatment because it treats a small area of the body.

What is radiotherapy used for, and when?

• After surgery to get rid of any remaining cancer cells in the breast area. This reduces the risk of the cancer coming back. If you have a lump or part of the breast removed you’ll usually have radiotherapy to the remaining breast tissue. If you have a mastectomy, you may be given radiotherapy to the chest area, particularly if the tumor is large or cancer cells have spread to the under the arm.
• After surgery to treat the lymph nodes above the collarbone and in the armpit. This will depend on the surgery you’ve had and whether or not the lymph nodes contained cancer cells. If all the lymph nodes have been removed, you'll not usually need radiotherapy to the armpit area.
• Before surgery to reduce the size of a large tumor. This is very uncommon.
• Before, after or during courses of chemotherapy. Radiotherapy is most commonly given after chemotherapy.
• To treat advanced stages of breast cancer. Radiotherapy can help to control previously untreated disease in the breast or help relieve cancer-related symptoms, such as pain caused by the cancer spreading to other parts of the body (secondary breast cancer).

What?

Electrical Impedance Scanning (EIS) is a diagnostic test that measures how electricity travels though tissue in the body. Some types of tissue have high electrical impedance, or resistance to conducting electricity, while others have lower electrical impedance. As cancerous breast tissue has a lower level of impedance, EIS is helpful in locating these breast abnormalities. EIS is also known as Transscan or T-Scan.

When?

EIS is commonly used in conjunction with mammography to detect breast cancer. EIS can also be used to reduce the number of biopsies required when ascertaining if a particular mass is cancerous.

How?

The device consists of a hand-held scanning probe and a computer screen that displays two-dimensional images of the breast. Although radiation-free, the device does emit a very small amount of electric current that is transmitted into the body to measure the level of impedance in the tissue. During the procedure, an electrode patch is placed on the patient’s arm. As current travels from the patch through the breast, the impedance level is measured by the scanning probe. When the device detects low levels of impedance (an indication of abnormalities in breast tissue), these areas show up as bright white spots on the computer screen.

FAQ

What are the advantages of this device?

The EIS can help confirm the location of abnormalities in breast tissues detected by a mammogram. As the image appears directly on a computer screen, a radiologist is able to move the probe around the abnormal area for the best views and thus reduce the total number of biopsies needed for an accurate result. It may also help identify women who require a biopsy.

Can this procedure be used to identify breast cancer?

EIS is not currently approved as a screening device for breast cancer. It is used as an adjunct to mammography.

After a mastectomy, it is often possible to reconstruct the breast area to restore the contour and original appearance of the breast. The surgery rebuilds the size and shape of the breast and, if desired, the nipple and areola (the darker area surrounding the nipple). Most women who have had a mastectomy can have reconstruction. Women who have had a lumpectomy usually do not need reconstruction.

Not all women want reconstruction, but if you think that it might make you feel more positive, ask if it’s available in your case. It may not be suitable for women with very advanced disease, nor those whose cancer is actively spreading.

Reconstructive surgery can be done immediately (the time the natural breast is removed) or later, when other treatment is completed. The advantage of immediate reconstruction is that you will need only one major operation.

Goals of reconstruction

Women choose breast reconstruction for different reasons. These reasons may be:

• To make the breasts look balanced when wearing a bra.
• To permanently regain the breast contour.
• To provide the convenience of not needing an external prosthesis.

Types of implants

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 debilitating immune system diseases.

Issues to consider before you opt for implants

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

Worrying about your appearance and wanting to look as good as you can are normal feelings. Some women think they are being vain or feel embarrassed if they ask about prostheses or wigs during treatment for cancer. But self-image and emotional well being plays an important role in the outcome of your treatment. So if wearing a headgear, wig or breast prostheses makes you feel better, then it’s well worth the effort!

Breast prostheses

A breast prosthesis is a false breast, which may or may not have a nipple. If you have decided against reconstruction, or are still in the process of making up your mind, you may want to find out about prosthesis.

All women who have had a mastectomy are strongly recommended to try out a properly fitted, weighted breast form. Before leaving the hospital, you should have had the opportunity to wear a much lighter, temporary prosthesis, while your scar is healing.

Within four to six weeks of surgery, you will be ready to be fitted for a permanent prosthesis. Some prostheses are made from silicone, and have the same weight, feel as a natural breast and last for two to four years. Silicone is waterproof and can be worn safely during most activities. There are also prostheses which are made from sponge or fibre.

Some prostheses can be attached directly to the skin with an adhesive strip. Others slip into a pocket in a special bra, which may be soft-cup or underwired. The bras are made with wider straps and a larger underband than regular bras, and are available in several different styles and colours. You will be able to wear most styles of clothing. Special swimming costumes are available, although you may still be able to wear an ordinary one.

Headgears and wigs

If your treatment includes chemotherapy, you may lose some or all of your hair. It is a good idea to think about what you would like to do before this happens. Some women find it helps boost their morale to have an attractive wig ready before chemotherapy starts – perhaps even to radically change their hair colour or style.

Alternatively you might also like to experiment with different hats and scarves.

Below are places where you can shop at for prostheses and wigs. They also stock items such as special swimwear and other post-surgery supplies.

AMANITA
Lot 1.06, 1st Flr, The Ampwalk,
218, Jalan Ampang,
50450 Kuala Lumpur
Tel: 03-2162 8215
Fax: 03-2163 6172
Website: www.amanita.com.my
E-mail: info@amanita.com.my

Breast Cancer Foundation also displays a few samples of AMANITA's breast prostheses and wig at our CBE Clinic in Section 5.

POSITIVE IMAGE
Hospital Putrajaya
Pusat Pentadbiran Kerajaan Persekutuan Presint 7,
62250 Putrajaya
Fax: 03-8888 3098

For more information on Positive Image, please call Yayasan Budi Penyayang Malaysia at 03-8946 0222.

Not enough can be said about the importance of a good dietary and fitness regime. Both are necessary for maintaining a healthy weight, as obesity has been associated with increased breast cancer risk, especially after menopause. Many studies have also consistently shown that a healthy weight may help reduce the risk of breast cancer as well prevent any recurrence after treatment. To help you estimate the healthy weight for you, use the Body Mass Index.

In addition, regular exercise and a healthy diet both offer other benefits, including:

• Increased self-esteem
• Lower levels of anxiety, depression and fatigue
• Improved quality of life and physical fitness
• Reduced risk of developing other cancers, heart disease and diabetes.

Nutrition

Although no food or diet can actually help prevent you from getting cancer, your choice of food can help lower your risk of getting the disease or from getting it again. Good nutrition is also crucial in helping to control the side effects of treatment and in recovery after treatment.

In general, and high in fruits, vegetables, whole grains are recommended. Of course, be sure to make exercise part of your dietary plan. Here’s what you should do to maintain a healthy diet:

• Dietary fat: There have been many studies examining the relationship between breast cancer incidence and fat intake, but a relationship between dietary fat and breast cancer occurrence has not been shown. However, since fat is high in calories and a diet high in saturated fat is not heart-healthy, a low-fat diet (where only about 30% of your total calorie intake is from fat) is recommended. Do eat foods high in omega-3 fatty acids, such as fatty fish (salmon, herring, tuna, mackerel and sardines), walnuts, flaxseeds and soybeans. Avoid red meats, which are high in saturated fats that contribute to heart disease.
• Alcohol: The consumption of alcohol is associated with an increased risk of breast cancer. Recent studies have all come to the same conclusion: that drinking alcohol is a risk factor for developing breast cancer. More importantly, it has been found that even small amounts can have a big effect. One drink a day can increase a postmenopausal woman’s chances of dying from breast cancer by 30% compared to women who did not consume any alcohol. For each drink consumed a day, the lifetime risk of woman developing breast cancer is increased by almost 10%. And it doesn’t matter the type of alcohol consumed – and this includes red wine, unfortunately – the effects are the same. Hence, total avoidance of alcohol is recommended.
• Fruits, vegetables and whole grains: Although fruit and vegetable consumption may not significantly reduce breast cancer risk, they contain phytochemicals and antioxidants that may be protective against other cancers and heart disease. At least five servings (or cups) per day is recommended. Vegetables such as broccoli, cauliflower, spinach (bayam), sawi, bok choy and brussels sprouts should be included as part of the diet. By eating more fruits, vegetables and whole grains, you will also be able to reduce the amount of fat and calories while adding more nutrients in your diet.
• Soy: There is conflicting opinion about the intake of soy foods such as soy nuts, soy beverages and soybeans, for women who had estrogen-positive breast cancer. A conservative recommendation for women who have a history of estrogen-positive breast cancer is three servings of whole soy foods a week. Concentrated sources of soy, such as soy protein powders, soy pills or supplements with concentrated isoflavones should be avoided.

Exercise

Staying physically active is vital for your overall health. If you’re undergoing radiation therapy or chemotherapy, or are recovering from surgery, exercise will not only help you feel better, but your body will be fitter and you’ll be able to maintain a healthy weight.

Many women struggle with weight gain during and after chemotherapy, gaining as much as 15 pounds, not from overeating but from the lack of physical activity. This weight gain can be a real problem, as energy levels can be very low after chemotherapy and many are too weak to get out of bed. However, it’s important to stay active, even by walking for just 10 minutes a day. And although chemotherapy also takes its toll on the immune system, exercise can help boost it, both physically but emotionally.

Fatigue is also a common symptom in those who undergo cancer treatments. Sometimes, the exhaustion may last a long time after treatment, hindering physical activity. Nonetheless, engaging in any form of exercise can be very helpful in reducing fatigue. Exercise can improve physical and emotional well being, endurance and strength, which fight fatigue and depression.

The key is to start slowly, with gentler exercises, such as walking, yoga, qigong and swimming, and then gradually increasing the duration of the time spent on the activity. And try not to do it alone - get support from family or friends, or do it with an exercise buddy! You will be treated by a team of professionals, including some or all of the following:

• General Practitioners (GP) – The one who usually arranges your first referral to a specialist breast clinic.
• Oncologist – A doctor who specializes in the diagnosis, treatment and rehabilitation of cancer patients. A clinical oncologist is trained in giving radiotherapy and chemotherapy, while a medical oncologist administers chemotherapy only.
• Radiologist – A medically qualified doctor who specializes in the use of imaging techniques (X-rays, ultrasound, CT etc) for diagnosis, and the one who will interpret your mammogram.
• Pathologist – A doctor specializing in identifying diseases by studying cells and tissues under a microscope.
• Radiographer – A non-medically qualified person who assists the radiologist in imaging and is trained in using X-ray machines. Some also give radiotherapy.
• Breast Surgeon – A specialist in breast surgery who also does fine needle aspiration and biopsy. Some may also do reconstructive surgery.
• Breast-care nurse – Nurse with special training in dealing with breast disease, who offers information, support and advice.
• Ward nurses – A nurse who plans your care on the ward.
• Physiotherapist – Gives you exercises to do after surgery for you to regain your strength and fitness.
• Psychologist – Professional counselling that can help you cope with your illness, and deal with decisions about treatment, depression, anxiety as well as family issues.
• Social worker – Can help you work out practical difficulties including transport, childcare and financial issues.

Olympic skater and cancer patient Peggy Fleming has once said, “Coping with breast cancer is almost easier for the woman, because she knows what her job is, while family members orbit around her in confusion, trying to figure out what to do, how to feel.”

That is not far from the truth. Breast cancer can have a profound effect on family members and friends. Unfortunately, a lot of literature and media stories deal with those who are suffering from breast cancer, and not for their family, friends and relatives.

Here are some tips to help family and friends cope when a loved one is suffering from breast cancer:

• Don’t be shy. Ask the doctor questions if you accompany your loved one to his or her appointments.
• Be prepared for unexpected mood and behavioral changes in your loved one. Medications, treatment, discomforts, and stress can cause your loved one to become depressed, dejected, angry or frustrated.
• Be supportive but do encourage your loved one to be active and independent, as much as possible, to help him or her regain a sense of self-reliance and confidence.
• Take care of yourself. Be aware of your own needs and make sure you are sleeping enough, eating properly, and taking some time off for yourself. There’s not much you can do if you are drained, irritable or unwell.
• Ask help from other family members, relatives and friends if you need it. More often than not, they would be more than happy to be of help.

If you’re a husband dealing with breast cancer, read this informative article on healthcentral.com, in which a writer shares his insights into coping and living for the first time with his wife who had breast cancer, as well as tips on the do’s and don’ts .

There are also many other resources available outside the circle of family and friends which can be helping and healing, including:

Social workers

Social workers are just one part of the care-giving team who can offer treatment in a compassionate setting. They also help address any concerns about the diagnosis, treatment or other personal questions related to the illness. Social workers are also trained and qualified to provide education, counselling regarding lifestyle changes as well as information on local community or support groups.

Individual Counseling

At times, a one-on-one counseling may be the best option to help a cancer survivor to deal with certain problems, such as depression, anger, guilt or frustration. A private session may help a survivor feel more secure and more likely to share and expressive his or her feelings. Counselling sessions can also be helpful to gather the survivor and his or her family members together to discuss issues of concern as well as effective coping strategies.

Support Groups

Support groups are a useful resource for breast cancer survivors as they can meet and share with other survivors their personal experience in battling the disease. It is a safe and empathetic environment in which a survivor can learn coping techniques from those who have been through similar experiences.

For more information on support groups in Malaysia, click here .

For a breast cancer patient, nothing can kill sexual desire faster than the daily nausea of chemotherapy, the vaginal dryness of premature menopause, and the ongoing fatigue associated with just about every stage of breast cancer treatment. It takes longer to get aroused, and when you do, sex can be painful. You may not like being touched in the same way that you did before. Your affected breast may be too sensitive to touch, or if you've had a mastectomy, a reconstructed breast won't feel your partner's caresses at all.

Ideas to spice it up!

• Communication is vital. Getting sex started again after a major life change is never easy, and may be awkward and embarrassing at first. If you have had a mastectomy or chemotherapy, you may feel sensitive about your changed appearance. Set aside time to talk to your partner and to listen to what he has to say. You may not feel ready for full intercourse but try to be specific about what you are prepared to do.
• Take one step at a time. Often a cuddle and a hug will be enough to bring you close at first and if you have discussed it in advance, it will not cause distrust or guilt if things go no farther at the time. Gradually, you will feel ready to move on to a wide range of sexual activities.
• Getting used to your new body. Sex after breast cancer has to do with your body image too. If you don't feel particular sexy about your new body just yet, there's nothing wrong with wearing a little lingerie to bed if it will help you feel more attractive and more in the mood.
• Think creatively. Be resourceful. For example, if you’re often too tired for sex at bedtime, try to find another time of day when you have more energy.
• Find solutions. The symptoms of menopause, especially vaginal dryness, may also be getting in the way, causing painful sexual intercourse. Take advantage of lubricants and keep them at your bedside.
• Don't neglect foreplay. Adequate stimulation is important for the vagina to be ready for intercourse.

Exposure to hormones, specifically estrogen, is thought to increase a woman’s risk of developing breast cancer. Throughout life, women are exposed to hormones. From their first menstrual cycle to the onset of menopause, estrogen and progesterone are stimulating normal breast cells. It is this lifetime exposure to ovarian hormones that is believed to put a woman at risk for breast cancer.

Still, it is not clear if estrogen or other hormones cause breast cancer. What is known is that a woman who has begins her menstrual cycle early before age 12, has her first child late after the age of 35 or have had no children, and goes through menopause late, after age 55 has an increased risk of breast cancer. Another potential risk is hormone therapy.

Hormone therapy (HRT)

During menopause, a woman’s body produces much lower amounts of estrogen and progesterone than when she was menstruating. Low levels of estrogen may cause hot flashes, bone loss, vaginal dryness and mood swings. To help lessen these side effects, doctors may prescribe hormone-based drugs (HRT).

Since HRT adds estrogen (and progestin for women who have a uterus) back to your body, many studies have looked for a possible link between the use of HRT and breast cancer. Recent studies have shown that HRT, especially combined estrogen and progestin, can increase the risk of breast cancer.

Although it is still unproven that estrogen directly causes breast cancer, estrogen may help some breast cancer cells grow when the tumor is already resent in a woman’s body. Some doctors are concerned that exposure to estrogen and/or progestin will increase a woman’s risk of breast cancer recurring. Research studies are still looking into this concern.

HRT - Weighing the benefits against the risks

Any woman currently taking or considering HRT should ask her doctor about potential risks and benefits.

Many women have taken HRT to relieve menopausal symptoms and to lower the risk of chronic diseases, like osteoporosis and heart disease. However, there is now strong evidence that most women should not use postmenopausal hormones to try to lower their risk of chronic disease.

On top of this, evidence also suggests that, although women take HRT to simply feel better, hormone use actually does little to increase women’s quality of life in their postmenopausal years, even in women with some significant symptoms, like severe hot flashes. And while hormone use can decrease the risk of some diseases, such benefits are overshadowed by an increase in the risk of other conditions.

For breast cancer survivors, avoiding postmenopausal hormones may be even more important than for the average woman, as survivors are already at higher risk of developing a second breast cancer. Currently, the prudent choice for most breast cancer survivors is to avoid the use of postmenopausal hormones altogether.