Breast Care Center

Introduction

More than 200,000 women are diagnosed with breast cancer every year. One in eight women have a chance of getting breast cancer. There are two million women living with breast cancer in the U.S.

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Breast Health

Regular breast examinations by a doctor—should be part of your regular physical and performed every three years beginning at age 20 and each year after age 40.

Breast self-examination—beginning at age 20, women should perform breast self-examinations to be more aware of how your breasts look and feel. A Breast Center health care provider can advise you of the best method for performing breast self-examinations and provide you with educational materials.

Routine Mammograms—as one of the most important tools in the early detection of breast cancer, this low-dose X-ray can reveal both harmless and cancerous growths when they are too small to be detected by you or your health care provider

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Risk Assessment

The Breast Cancer Risk Assessment Tool is an interactive tool designed by scientists at the National Cancer Institute (NCI) and the National Surgical Adjuvant Breast and Bowel Project (NSABP) to estimate a woman's risk of developing invasive breast cancer. The tool has been updated for African American women based on the Contraceptive and Reproductive Experiences (CARE) Study. See About the Tool for more information.

Before using the tool, please note the following:

The Breast Cancer Risk Assessment Tool was designed for use by health professionals. If you are not a health professional, you are encouraged to discuss the results and your personal risk of breast cancer with your doctor.
The tool should not be used to calculate breast cancer risk for women who have already had a diagnosis of breast cancer, lobular carcinoma in situ (LCIS), or ductal carcinoma in situ (DCIS).
The BCRA risk calculator may be updated periodically as new data or research becomes available.
Although the tool has been used with success in clinics for women with strong family histories of breast cancer, more specific methods of estimating risk are appropriate for women known to have breast cancer-producing mutations in the BRCA1 or BRCA2 genes.
Other factors may also affect risk and are not accounted for by the tool. These factors include previous radiation therapy to the chest for the treatment of Hodgkin lymphoma or recent migration from a region with low breast cancer rates, such as rural China. The tool's risk calculations assume that a woman is screened for breast cancer as in the general U.S. population. A woman who does not have mammograms will have somewhat lower chances of a diagnosis of breast cancer.
For information to help your patients understand cancer risk visit http://understandingrisk.cancer.gov. This interactive Web site will help your patients make informed decisions about how to lower their risk.

USE RISK CALCULATOR

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Diagnosis

There are different types of biopsy methods. These include:

Fine Needle Aspiration (FNA)
During this procedure, the doctor inserts a very thin needle into the suspicious area of the breast. Cells or fluid are withdrawn (aspirated) from the lump and placed on a slide for examination under a microscope by a pathologist. This type of biopsy is relatively quick, and any discomfort lasts only a few seconds.
Core Needle Biopsy
A core needle biopsy may be used if a tissue sample larger than can be obtained with a fine needle aspiration biopsy is needed, or if the tissue removed during a needle aspiration biopsy does not yield a definitive diagnosis. This type of biopsy requires a local anesthetic. The doctor inserts a larger, hollow needle into the breast. A thin cylinder of tissue about one inch long is removed and is sent to a pathologist for analysis.
Image-Guided Biopsy
If the suspicious area cannot be felt, then a radiologist can use imaging techniques to biopsy the area. The choice of ultrasound, stereotactic mammographic imaging, or MRI depends on what the abnormality looks like and which technique is most appropriate for visualizing it.
Surgical Biopsy
- A surgical biopsy may be done if other biopsy procedures do not provide a definitive diagnosis. A surgical biopsy is also performed if the suspicious area is too deep or too superficial for a core biopsy.
- If the surgeon cannot feel the area in question, then the radiologist will insert a thin wire into the breast using mammography, ultrasound, or MRI to localize the area for the surgeon. This process is called a needle localization.
- A surgical biopsy takes place in an operating room, but it does not usually require an overnight stay in the hospital. During a surgical biopsy, the patient undergoes "twilight" sedation, but does not require general anesthesia. Under sterile conditions, a small incision is made on the breast; the suspicious breast tissue is removed entirely, or a representative sample is removed for analysis.

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Staging

The following stages are used for breast cancer:

Stage 0 (carcinoma in situ)

There are 2 types of breast carcinoma in situ:

Ductal carcinoma in situ (DCIS) is a noninvasive condition in which abnormal cells are found in the lining of a breast duct. The abnormal cells have not spread outside the duct to other tissues in the breast. In some cases, DCIS may become invasive cancer and spread to other tissues, although it is not known at this time how to predict which lesions will become invasive.
Lobular carcinoma in situ (LCIS) is a condition in which abnormal cells are found in the lobules of the breast. This condition seldom becomes invasive cancer; however, having lobular carcinoma in situ in one breast increases the risk of developing breast cancer in either breast.

Pea, peanut, walnut, and lime show tumor sizes.

Stage I

In stage I, cancer has formed. The tumor is 2 centimeters or smaller and has not spread outside the breast.

Stage II A

In stage II A

no tumor is found in the breast, but cancer is found in the axillary lymph nodes (the lymph nodes under the arm); or
the tumor is 2 centimeters or smaller and has spread to the axillary lymph nodes; or
the tumor is larger than 2 centimeters but not larger than 5 centimeters and has not spread to the axillary lymph nodes.

Stage II B

In stage II B, the tumor is either:

larger than 2 centimeters but not larger than 5 centimeters and has spread to the axillary lymph nodes; or
larger than 5 centimeters but has not spread to the axillary lymph nodes.

Stage III A

In stage III A

no tumor is found in the breast. Cancer is found in axillary lymph nodes that are attached to each other or to other structures, or cancer may be found in lymph nodes near the breastbone; or
the tumor is 2 centimeters or smaller. Cancer has spread to axillary lymph nodes that are attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone; or
the tumor is larger than 2 centimeters but not larger than 5 centimeters. Cancer has spread to axillary lymph nodes that are attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone; or
the tumor is larger than 5 centimeters. Cancer has spread to axillary lymph nodes that may be attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone.

Stage III B

In stage III B, the tumor may be any size and cancer:

has spread to the chest walland/or the skin of the breast; and
may have spread to axillary lymph nodes that may be attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone.

Cancer that has spread to the skin of the breast is inflammatory breast cancer. See the section on Inflammatory Breast CancerInflammatory Breast Cancer for more information.

Stage III C

In stage III C, there may be no sign of cancer in the breast or the tumor may be any size and may have spread to the chest wall and/or the skin of the breast. Also, cancer:

has spread to lymph nodes above or below the collarbone; and
may have spread to axillary lymph nodes or to lymph nodes near the breastbone

Cancer that has spread to the skin of the breast is inflammatory breast cancer. See the section on Inflammatory Breast Cancer for more information.

Stage IIIC breast cancer is divided into operable and inoperable stage IIIC.

In operable stage IIIC, the cancer:

is found in ten or more axillary lymph nodes; or
is found in lymph nodes below the collarbone; or
is found in axillary lymph nodes and in lymph nodes near the breastbone.

In inoperable stage IIIC breast cancer, the cancer has spread to the lymph nodes above the collarbone.

Stage IV

In stage IV, the cancer has spread to other organs of the body, most often the bones, lungs, liver, or brain.

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Prevention

High risk women or women with atypia in the breast may consider prevention with tamoxifen or raloxifene for five years. This is a proven strategy to reduce the risk of breast cancer by 50% but needs to be discussed with an oncologist.

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Treatment

Five types of standard treatment are used:

Surgery

Most patients with breast cancer have surgery to remove the cancer from the breast. Some of the lymph nodes under the arm are usually taken out and looked at under a microscope to see if they contain cancer cells.

Breast-conserving surgery, an operation to remove the cancer but not the breast itself, includes the following:

Lumpectomy: Surgery to remove a tumor(lump) and a small amount of normal tissue around it.
Partial mastectomy: Surgery to remove the part of the breast that has cancer and some normal tissue around it. This procedure is also called a segmental mastectomy.

biopsy

lymph node dissection

incision

Total mastectomy: Surgery to remove the whole breast that has cancer. This procedure is also called a simple mastectomy. Some of the lymph nodes under the arm may be removed for biopsy at the same time as the breast surgery or after. This is done through a separate incision.

Total (simple) mastectomy. The dotted line shows where the entire breast is removed. Some lymph nodes under the arm may also be removed.
Modified radical mastectomy: Surgery to remove the whole breast that has cancer, many of the lymph nodes under the arm, the lining over the chest muscles, and sometimes, part of the chest wall muscles.

Modified radical mastectomy. The dotted line shows where the entire breast and some lymph nodes are removed. Part of the chest wall muscle may also be removed.
Radical mastectomy: Surgery to remove the breast that has cancer, chest wall muscles under the breast, and all of the lymph nodes under the arm. This procedure is sometimes called a Halsted radical mastectomy.

breast reconstruction

Radiation Therapy

Chemotherapy

regional chemotherapy

Hormone Therapy

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Support

Support groups twice a month
Clinical Psychologist for one on one counseling
Nutrition counseling and support

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Our Team

San Diego Cancer Center Breast care program is a multidisciplinary comprehensive program that provides high risk testing and prevention of breast cancer and treatment of all stages of breast cancer.We work closely with all surgeons and radiation oncologists in the community and UCSD to individualize patient care. Multidisciplinary tumor boards are held twice a month to review radiology and discuss each patient’s treatment plan.

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Dr. Rupa Subramanian

Dr. Rupa Subramanian is a board certified oncologist with ten years experience in treating breast cancer.

She has trained with breast cancer specialists at UCLA and UC Irvine. She has established breast care centers in Orange County and San Diego.

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Brochure

View our Breast Care Center brochure.

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Resources

Breast Cancer Information for patients and family members www.breastcancer.org

Useful information for patients "people living with cancer" offers interactive sessions with research leaders www.plwc.org

American Cancer Society's Breast Cancer Informational Resources

Breast Cancer Organizations

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Lymphedema Prevention

Lymphedema: What Every Woman With Breast Cancer Should Know from ACS

Why do I need to know about lymphedema?

Women who have been treated for breast cancer may be at risk for arm, breast, and chest swelling called lymphedema (limf-uh-dee-muh). Most women who have had breast cancer will not develop this side effect, but many will. The risk of lymphedema is higher for women who have surgery and radiation therapy to treat breast cancer.

What is the lymph system?

Our bodies have a network of lymph (limf) nodes and lymph vessels that collect watery, clear lymph fluid, much like veins collect blood from all parts of the body and carry it through the body. Lymph fluid contains proteins, salts, and water, as well as white blood cells, which help fight infections. In the lymph vessels, valves work with body muscles to help move the fluid through the body. Lymph nodes are small collections of tissue that work as filters for harmful substances and help us fight infection.

The network of lymph nodes and vessels.

What is lymphedema?

During surgery for breast cancer, the doctor removes at least one lymph node from the underarm area to see if the cancer has spread. Sometimes doctors remove more than one. When lymph nodes are removed, the lymph vessels that carry fluid from the arm to the rest of the body are also removed because they are wrapped around the nodes.

Removing lymph nodes and vessels changes the way the lymph fluid flows in that side of the upper body. This makes it harder for fluid in the chest, breast, and arm to flow out of this area. If the remaining lymph vessels cannot drain enough of the fluid from these areas, the excess fluid builds up and causes swelling, or lymphedema. Radiation treatment to the lymph nodes in the underarm can affect the flow of lymph fluid in the arm and breast area in the same way, further increasing the risk of lymphedema.

Lymphedema is a build-up of lymph fluid in the fatty tissues just under your skin. It usually develops slowly over time. The swelling can range from mild to severe. It can start soon after surgery or radiation treatment. But it can also begin months or even many years later. Women who have many lymph nodes removed and women who have had radiation therapy to the breast and/or underarm area may have a higher risk of getting lymphedema.

How to reduce swelling after surgery or radiation

Right after surgery, the affected arm or breast area may swell. This swelling is usually short-term and slowly goes away over the next 6 to 12 weeks. These tips may help ease the swelling during this time:

Use your affected arm as you normally would to do things like comb your hair, bathe, dress, and eat.
Raise your affected arm above the level of your heart 2 or 3 times a day and keep it there for 45 minutes. Lie down to do this, and fully support your arm. Put your arm up on pillows so that your hand is higher than your wrist and your elbow is a little higher than your shoulder.
Exercise your affected arm while it is supported above the level of your heart by opening and closing your hand 15 to 25 times. Repeat this 3 to 4 times a day. This exercise helps reduce swelling by pumping lymph fluid out of the arm through the undamaged lymph vessels.
To get back your normal shoulder and arm movement, begin exercising your affected arm about a week after your surgery. But talk to your doctor, nurse, or physical therapist before doing any exercises. For most people, normal range of motion returns within 4 to 6 weeks.
If you have radiation therapy after surgery, it may cause arm swelling or make the swelling last longer than it normally would after surgery. It may also cause some swelling in the chest and breast toward the end of the treatment. In most cases, this swelling is short-term and will slowly go away. During treatment and up to 18 months afterward, you should do simple stretching exercises each day to keep full movement in your chest, arm, and shoulder.

How to help prevent and control lymphedema

At this time there are no scientific studies to show that women can prevent lymphedema. Still, most experts say following these basic guidelines may lower your risk of developing lymphedema or delay its onset.

following these basic guidelines may lower your risk of developing lymphedema or delay its onset. Try to avoid infection

Whenever possible, have your blood drawn, IVs, and shots given in your unaffected arm. Also have flu shots and vaccinations in your unaffected arm or somewhere else, like the hip. Tell your doctor or nurse that you are at risk for lymphedema.
Keep your hands and cuticles soft and moist by regularly using moisturizing lotion or cream. This will help keep your skin from chapping and cracking. Push your cuticles back with a cuticle stick rather than cutting them with scissors.
Keep your arm clean. Clean and protect any skin openings caused by cuts, scratches, insect bites, hangnails, or torn cuticles. First, wash it with soap and water. Then use an over-the-counter antibiotic cream or ointment and cover the area with a clean bandage. Check with your doctor, nurse, or pharmacist if you are not sure what to use.
Wear protective gloves when doing household chores that use chemical cleansers or steel wool, when gardening or doing yard work, and maybe when washing dishes.
Wear a thimble when sewing to avoid needle and pin pricks to your finger.
Use an electric shaver to remove underarm hair; it may be less likely to cut or irritate the skin than a blade razor or hair removal cream.
Use an insect repellent to avoid bug bites when outdoors. If you are stung by a bee in the affected arm, clean and put ice on the area, raise the arm, and call your doctor or nurse if the sting shows any signs of getting infected.
Avoid extreme cold. It can cause rebound swelling as you warm up and chapping of your skin, which may lead to infection.

Try to avoid burns

Like infections, burns can cause the body to make extra fluid that may build up and cause swelling when lymph nodes have been removed or damaged. Tips to avoid burns include:

Protect your chest, shoulder, and arm from sunburn. Use sunscreen labeled SPF 15 or higher and try to stay out of the sun during the hottest part of the day.
Use oven mitts that cover your arms.
Avoid oil splash burns from frying and steam burns from microwaved foods or boiling liquids.
Avoid high heat, such as from hot tubs and saunas. And do not use heating pads on the affected areas. Heat can increase fluid build-up.

Try to avoid constriction

Constriction or squeezing of the arm may increase the pressure in nearby blood vessels. This may lead to increased fluid and swelling (much like water building up behind a dam). Some women have linked this with the start of lymphedema. Lymphedema has also been linked with air travel, possibly because of the low cabin pressure. Tips include:

Wear loose jewelry, clothing, and gloves. Avoid anything that forms a snug band around your arm or wrist.
Do not use shoulder straps when carrying briefcases and purses.
Wear a loose-fitting bra with padded straps that do not dig into your shoulder. After mastectomy, use a lightweight prosthesis (breast form). A heavy prosthesis may put too much pressure on the area.
Do not have your blood pressure taken on the affected arm. If both arms are affected, blood pressure can be taken on your thigh.
On long or frequent flights, wear a compression sleeve. A well-fitted compression sleeve may help prevent swelling by helping to squeeze the lymph fluid through the remaining vessels before it builds up. But careful fitting is required, since any garment that is too tight near the top can actually reduce the lymph flow. Ask your doctor or physical therapist if you should be fitted for a sleeve to wear during air travel. You may also want to discuss ways to safely raise your arm above the level of your heart and exercise it during long flights.

Try to avoid muscle strain

It's important to use your affected arm for normal everyday activities to help you to heal properly and regain strength. This includes doing things like brushing your hair and bathing. Using your muscles also helps drain lymph fluid from the limbs. If you’ve had surgery or radiation treatment, ask your doctor or nurse when you can begin to exercise and what type of exercises you can do. But keep in mind that overuse, which can result in injury, has been linked with the start of lymphedema in some women. It's a good idea to follow these tips:

Use your affected arm as normally as you can. Once you are fully healed, about 4 to 6 weeks after surgery or radiation treatment, you can begin to go back to the activities you did before your surgery.
Exercise regularly but try not to over-tire your shoulder and arm. Before doing any strenuous exercise, such as lifting weights or playing tennis, talk with your doctor, nurse, or physical therapist. They can help you set goals and limits so that you can work at the level of activity that is right for you. Ask your doctor or physical therapist if you should be fitted for a sleeve to wear during strenuous activities.
If your arm starts to ache, lie down and raise it above the level of your heart.
Avoid vigorous, repeated activities, heavy lifting, or pulling.
Use your unaffected arm or both arms as much as possible to carry heavy packages, groceries, handbags, or children.

Try to avoid gaining weight

Extra fat requires more blood vessels. This creates more fluid in the arms and chest, and places a greater burden on the lymph vessels that are left. At least 2 studies have found that gaining weight after mastectomy is linked to a higher risk of lymphedema. Women who are more overweight (obese) were more likely to have severe lymphedema.

How to care for cuts, scratches, or burns

Wash the area with soap and water.
Put an antibiotic cream or ointment on the area.
Cover with a clean, dry gauze or bandage.
For burns, apply a cold pack or cold water for 15 minutes, then wash with soap and water and put on a clean, dry dressing.
Watch for early signs of infection: pus, rash, red blotches, swelling, increased heat, tenderness, chills, or fever.
Call your doctor right away if you think you may have an infection.

Signs of lymphedema

The signs of lymphedema may include:

swelling in the breast, chest, shoulder, arm, or hand
area feels full or heavy
skin changes texture, feels tight or hard, or looks red
new aching or discomfort in the area
less movement or flexibility in nearby joints, such as your shoulder, hand, or wrist
trouble fitting your arm into jacket or shirt sleeves
bra doesn't fit the same
ring, watch, and/or bracelet feels tight but you have not gained weight

Early on, the lymphedema may be relieved by raising the affected limb and the skin usually stays soft. But over time, the swollen area may become hot and red and the skin hard and stiff.

If you have had any type of breast surgery, lymph nodes removed, or radiation treatment, look at your upper body in front of a mirror. Compare both sides of your body and look for changes in size, shape, or skin color. If you notice any of the signs listed above, and if they last for 1 to 2 weeks, call your doctor or nurse.

When to call your doctor or nurse

if you notice any swelling, with or without pain, that lasts for 1 to 2 weeks
if any part of your affected arm, chest, breast, or underarm area (axilla) feels hot, looks red, or swells suddenly. These could be a sign of infection and you may need antibiotics
if you have a temperature of 100.5°F or higher (taken by mouth) that is not related to a cold or flu
if you have any new pain in the affected area with no known cause

Lymphedema Treatment

If you are diagnosed with lymphedema, there are treatments to reduce the swelling, keep it from getting worse, and decrease the risk of infection. The treatment is prescribed by your doctor and should be given by an experienced therapist. Be sure to check your health insurance to make sure the treatment is covered.

Mild lymphedema should be treated by a physical therapist or other health care professional who has gone through special training. Moderate or severe lymphedema is most often treated by a therapist with special training and expertise who will help you with skin care, massage, special bandaging, exercises, and fitting for a compression sleeve. This is sometimes known as complex decongestive therapy, or CDT. Manual lymphatic drainage, or MLD, is a type of massage used along with skin care, compression therapy, and exercise to manage lymphedema.

Although most insurance companies will pay for lymphedema treatment, some do not cover the cost of compression garments and dressings. Check with your insurance company about coverage for these therapies.

Additional Resources

Lymphedema: Understanding and Managing Lymphedema After Cancer Treatment is a book you can buy from your American Cancer Society. Please call 1-800-ACS-2345 for cost and ordering information.

National organizations and Web sites*

Along with your American Cancer Society, other sources of information and support include:

Lymphology Association of North America (LANA)
Telephone: 773-756-8971 (Illinois)
Web site: www.clt-lana.org
Web site lists therapists, nurses, and physicians who specialize in treating lymphedema.

National Lymphedema Network (NLN)
Toll-free number: 1-800-541-3259
Web site: www.lymphnet.org

Susan G. Komen for the Cure
Toll-free number: 1-877-465-6636
Web site: www.komen.org

Breast Cancer Network of Strength
Toll-free number: 1-800-221-2141 (English);1-800-986-9505 (Spanish)
Web site: www.networkofstrength.org

New Patients

Elena O Brien – Phone: 760-598-1700, ext. 150, Fax: 760-598-1196 for new patient referrals
Email breast@sdcancer.com to be on mailing list for breast tumor boards with 1hr CME credit on 1st and 3rd Tuesdays at 12 noon in Encinitas campus
Sign up for emails monthly with latest updates on breast cancer.

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Breast Care Center

Introduction

Breast Health

Risk Assessment

Before using the tool, please note the following:

Diagnosis

Staging

Prevention

Treatment

Support

Our Team

Dr. Rupa Subramanian

Brochure

Resources

Lymphedema Prevention

Why do I need to know about lymphedema?

What is the lymph system?

What is lymphedema?

How to reduce swelling after surgery or radiation

How to help prevent and control lymphedema

Try to avoid muscle strain

Try to avoid gaining weight

How to care for cuts, scratches, or burns

Signs of lymphedema

When to call your doctor or nurse

Lymphedema Treatment

Additional Resources

National organizations and Web sites*

New Patients