Abramson Cancer Center

Penn Medicine recognizes that every case of breast cancer is unique, with different signs and symptoms, risk factors, and prevention strategies. All women are at risk for breast cancer, and that risk increases with age.

Breast Cancer Prevention

While there's no guaranteed way to prevent breast cancer, Penn Medicine encourages women to be screened regularly, increasing the chances that breast cancer will be found early when it's most treatable. All women should know the symptoms and warning signs of breast cancers.

Women should talk with their doctor about specific preventive measures they can take.

As with most cancers, knowing the family history of breast cancer can help patients take action toward prevention.

Women who are or may be at increased risk can take steps to reduce their chances of developing breast cancer. Before deciding, they should speak with their doctor to understand the risk and how much any of these approaches might lower their risk.

The Mariann and Robert MacDonald Womens' Cancer Risk Evaluation Center at the Abramson Cancer Center and the Cancer Risk Evaluation Program at Pennsylvania Hospital's Joan Karnell Cancer Center and Penn Medicine at Radnor are designed for women who want information about their risk for breast and ovarian cancers. These programs offer clinical and research services that can help people with cancer and individuals who may be at an increased risk for cancer.

Breast Cancer Risk Factors

Risk factors affect the chance of getting breast cancer, Having a risk factor, or even several, does not mean that someone will get breast cancer. Most women who have one or more breast cancer risk factors never develop the disease, while many women with breast cancer have no apparent risk factors (other than being a woman and growing older).

There are different kinds of risk factors. Some factors, like age or race, can't be changed. Risk factors for breast cancer that cannot change include:

• Gender. Being a woman is the leading risk factor for developing breast cancer. The chance of a woman developing invasive breast cancer some time during her life is just under one in eight.
• Aging. The risk of developing breast cancer increases as women get older.
• Menstrual periods. Women who have had more menstrual cycles because they started menstruating at an early age (before age 12) and/or went through menopause at a later age (after age 55) have a slightly higher risk of breast cancer.
• Genetics. Between 5 and 10 percent of breast cancer cases are thought to be hereditary, resulting directly from gene defects (called mutations) inherited from a parent, including BRCA1 and BRCA2.
• Family history. Breast cancer risk is higher among women whose close blood relatives have the disease.
• Personal history. Women with cancer in one breast have a three- to four-fold increased risk of developing a new cancer in the other breast or in another part of the same breast.
• Race and ethnicity. Caucasian women are slightly more likely to develop breast cancer than are African-American women, but African-American women are more likely to die of breast cancer. Asian, Hispanic, and Native-American women have a lower risk of developing and dying from breast cancer.
• Dense breast tissue. Women with dense breasts (as seen on a mammogram) have more glandular tissue and less fatty tissue, and are at higher risk of breast cancer. In addition, dense tissue and tumors have similar density so tumors can be harder to detect in women with denser breasts.
• Benign breast conditions. Women diagnosed with certain benign breast conditions may have an increased risk of breast cancer. Benign conditions include:
  • Non-proliferative (non-spreading) lesions.
  • Proliferative (spreading) lesions without atypia.
  • Proliferative (spreading) lesions with atypia.
• Lobular carcinoma in situ. Women with lobular carcinoma in situ (LCIS) have a 7- to 11-fold increased risk of developing cancer in either breast.
• Previous chest radiation. Women who had radiation therapy to the chest area as treatment for another cancer (such as Hodgkin disease or non-Hodgkin lymphoma), especially before the age of 30, are at significantly increased risk for breast cancer.
• Diethylstilbestrol exposure. From the 1940s through the 1960s, some pregnant women were given the drug diethylstilbestrol (DES) because it was thought to lower their chances of miscarriage. These women have a slightly increased risk of developing breast cancer. Women whose mothers took DES during pregnancy may also have a slightly higher risk of breast cancer.

Lifestyle risk factors can be changed, potentially lowering the risk of breast cancer. Lifestyle-related factors that increase the breast cancer risk include:

• Not having children, or having them later in life.
• Taking post-menopausal combination hormone replacement therapy such as estrogen and progesterone. Estrogen-alone therapy is not believed to increase the risk of breast cancer.
• Alcohol use. The risk for developing breast cancer increases with the amount of alcohol consumed.
• Being overweight or obese.
• Lack of physical activity.

Risk Factors for Men

Men have different kinds of breast cancer risk factors. Some, like age or race, can't be changed. Risk factors for breast cancer that cannot change include:

• Aging. The risk of developing breast cancer increases as men get older. Men with breast cancer are, on average, about 67 years old when they are diagnosed.
• Genetics. Male breast cancer can be hereditary, resulting directly from gene defects (called mutations) inherited from a parent, including BRCA1 and BRCA2.
• Family history. About one out of five men with breast cancer have close male or female relatives with the disease.
• Personal history. Men with cancer in one breast have an increased risk of developing a new cancer in the other breast or in another part of the same breast.
• Klinefelter syndrome. This congenital condition (present at birth) affects about one in 1,000 men. Normally the cells in men's bodies have a single X chromosome along with a Y chromosome, while women's cells have two X chromosomes. Men with this condition have cells with more than one X chromosome (sometimes as many as four).
• Radiation exposure. A man whose chest area has been treated with radiation (usually for treatment of a cancer inside the chest, such as lymphoma) has an increased risk of developing breast cancer.
• Drinking. Heavy drinking of alcoholic beverages increases the risk of breast cancer in men.
• Liver disease. Men with severe liver disease, such as cirrhosis, have relatively low levels of androgens and higher estrogen levels. Therefore, they may have an increased risk of developing breast cancer.
• Estrogen treatment. Estrogen-related drugs are sometimes used in hormonal therapy for men with prostate cancer. This treatment may slightly increase their breast cancer risk. However, this risk is small compared with the benefits of this treatment in slowing the growth of prostate cancer.
• Conditions affecting the testicles. Some studies have suggested that certain conditions that affect the testicles, such as having an undescended testicle, having mumps as an adult, or having one or both testicles surgically removed (orchiectomy) may increase breast cancer risk.
• Certain occupations. Some reports have suggested an increased risk in men who work in hot environments such as steel mills. This could be because long-term exposure to higher temperature can affect the testicles, which in turn affects hormone levels. Men heavily exposed to gasoline fumes may also have a higher risk.

Breast Cancer Risk Assessment

The Cancer Risk Evaluation Program (CREP) at Penn offers knowledge about the presence of genetic risk for cancer and provides patients with important, sometimes life-saving options.
All women, regardless of racial or ethnic background, who have a BRCA1 or BRCA2 gene mutation are at increased risk for developing breast and/or ovarian cancer. Women at risk can discuss monitoring and preventive options to reduce their chances of developing breast and/or ovarian cancer with a Penn Medicine physician at the Abramson Cancer Center, Joan Karnell Cancer Center at Pennsylvania Hospital or Penn Medicine at Radnor.
As leading experts in the diagnosis and management of genetic risk for breast cancer, Penn Medicine's multidisciplinary team can coordinate care for those with known or suspected genetic risk.

After providing detailed information about their family history of cancer and medical history, participants in the program are scheduled for two appointments:

• One with a genetic counselor to assess risk and arrange genetic testing if indicated.
• A second appointment with a medical oncologist for results, an examination and medical recommendations.

Penn's Cancer Risk Evaluation Program also provides second opinions and long-term follow-up care.

Following the evaluation, a detailed report outlining the risk assessment, genetic testing results and medical recommendations is provided to participants. Assistance in arranging follow-up care is also available.

The Mariann and Robert MacDonald Womens' Cancer Risk Evaluation Center at the Abramson Cancer Center and the Cancer Risk Evaluation Program at the Joan Karnell Cancer Center are designed for women who want information about their risk for breast and ovarian cancers. These programs offer clinical and research services that can help people with cancer and individuals who may be at an increased risk for cancer.

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• Ductal carcinoma in situ (DCIS)
• Invasive (infiltrating) ductal carcinoma (IDC)
• Invasive (infiltrating) lobular carcinoma (ILC)
• Inflammatory breast cancer (IBC)
• Male breast cancer
• Other types of breast cancer

There are many types of breast cancer and sometimes a breast tumor can be a mix of these types. Every cancer and every person is different. Penn's breast cancer teams work with patients to choose the treatment approach and option that are best. The following information includes some of the options by cancer type and stage the team may recommend.

Ductal carcinoma in situ (DCIS)

Ductal carcinoma in-situ is breast cancer that starts in and is contained within the milk ducts, but has not spread through the wall of the duct. It does not have the potential to spread and has an excellent prognosis.

DCIS generally has no signs or symptoms and is most commonly picked up by a finding on screening mammogram. Less commonly, it can present with a lump or mass, or nipple discharge.

DCIS is considered stage 0. Treatment options include lumpectomy and radiation or mastectomy. In selected cases, tumor removal alone can be offered. No chemotherapy is needed. Medications like tamoxifen can be offered in hormone receptor positive cases to reduce the risk of recurrence.

Invasive (infiltrating) ductal carcinoma (IDC)

Invasive (infiltrating) ductal carcinoma (IDC), starts in a milk duct, breaks through the wall of the duct, and invades the tissue of the breast. IDC is the most commonly diagnosed breast cancer. Invasive ductal carcinoma accounts for about 8 out of 10 of all cases of invasive breast cancers.

IDC may feel like a hard, bumpy, irregularly shaped lump in the breast. The most common symptoms of IDC are a change in the look or feel of the breast or the nipple, a breast mass or a suspicious finding on a mammogram. Less common signs of IDC may include nipple discharge.

Treatments for stage I, II, III and operable stage III may include:

• Breast-conserving surgery to remove only the cancer and some surrounding breast tissue, followed by lymph node dissection and radiation therapy.
• Modified radical mastectomy with or without breast reconstruction surgery.
• Sentinel lymph node biopsy followed by surgery.
• Adjuvant therapy (treatment given after surgery to increase the chances of a cure) that may include:
  • Radiation therapy to the lymph nodes near the breast and to the chest wall after a modified radical mastectomy.
  • Systemic chemotherapy with or without hormone therapy.
  • Hormone therapy.
• Clinical trials.

Treatment of stage IIIB and inoperable stage IIIC breast cancer may include:

• Systemic chemotherapy.
• Systemic chemotherapy followed by surgery (breast-conserving surgery or total mastectomy), with lymph node dissection followed by radiation therapy.
• Additional systemic therapy (chemotherapy, hormone therapy, or both).
• Clinical trials.

Treatment of stage IV or metastatic breast cancer may include the following:

• Hormone therapy and/or systemic chemotherapy.
• Radiation therapy and/or surgery for relief of pain and other symptoms.
• Clinical trials.

Invasive (infiltrating) lobular carcinoma (ILC)

Invasive lobular carcinoma (ILC) is lobular carcinoma that has spread, or invaded, the nearby tissue outside of the lobes. ILC has the potential to spread, or metastasize, to other parts of the body.

ILC does not always feel like a breast lump. ILC cells may leave the lobes through one opening, staying together in a line. They can proceed to infiltrate fatty tissue, creating a web-like mass. This web of cancer cells may feel like a thickened area of breast tissue, and at first may not cause concern or pain. Unfortunately, if left undetected, ILC can develop into a large mass before causing more noticeable symptoms.

Treatments for stage I, II, III and operable stage III may include:

• Breast-conserving surgery to remove only the cancer and some surrounding breast tissue, followed by lymph node dissection and radiation therapy.
• Modified radical mastectomy with or without breast reconstruction surgery.
• Sentinel lymph node biopsy followed by surgery.
• Adjuvant therapy (treatment given after surgery to increase the chances of a cure) that may include:
  • Radiation therapy to the lymph nodes near the breast and to the chest wall after a modified radical mastectomy.
  • Systemic chemotherapy with or without hormone therapy.
  • Hormone therapy.
• Clinical trials.

Treatment of stage IIIB and inoperable stage IIIC breast cancer may include:

• Systemic chemotherapy.
• Systemic chemotherapy followed by surgery (breast-conserving surgery or total mastectomy), with lymph node dissection followed by radiation therapy.
• Additional systemic therapy (chemotherapy, hormone therapy, or both).
• Clinical trials.

Treatment of stage IV or metastatic breast cancer may include the following:

• Hormone therapy and/or systemic chemotherapy.
• Radiation therapy and/or surgery for relief of pain and other symptoms.
• Clinical trials.

Inflammatory breast cancer (IBC)

Inflammatory breast cancer (IBC) is a rare but aggressive type of breast cancer in which the cancer cells block the lymph vessels in the skin of the breast. This type of breast cancer is called “inflammatory” because the breast often looks swollen and red. Penn Medicine estimates 1 to 4 percent of breast cancer cases are IBC.

IBC affects the lymphatic system of the skin of the breast, so it does not present as a traditional lump. It tends to be diagnosed in younger women and it occurs more frequently and at a younger age in African Americans. Like other types of breast cancer, IBC can occur in men, but usually at an older age than in women.

Making the right diagnosis is a critical component of successful IBC treatment. Penn's cancer specialists have extensive experience in understanding the results and creating cancer treatment plans that are customized for every patient.

IBC is usually classified as stage III breast cancer. The treatment involves neoadjuvant chemotherapy, possibly followed by surgery, radiation, hormone therapy, biologic therapy or a combination of such treatments.

Male breast cancer

Men are not exempt from breast cancer. Male breast cancer makes up less than one percent of all breast cancer cases, but men at any age may develop breast cancer. The following types of breast cancer are found in men:

• Invasive ductal carcinoma. Cancer that has spread beyond the cells lining the ducts in the breast. Most men with breast cancer have this type of cancer.
• Ductal carcinoma in situ. Abnormal cells that are found in the lining of a duct.
• Inflammatory breast cancer. A type of cancer in which the breast looks red and swollen and feels warm.
• Paget disease of the nipple. A tumor that has grown from ducts beneath the nipple onto the surface of the nipple.

Treatment options for stage 0 male breast cancer include lumpectomy and radiation or mastectomy. In selected cases, tumor removal alone can be offered. No chemotherapy is needed.

Treatments for stage I, II, III and operable stage III may include:

• Breast-conserving surgery to remove only the cancer and some surrounding breast tissue, followed by lymph node dissection and radiation therapy.
• Modified radical mastectomy with or without breast reconstruction surgery.
• Sentinel lymph node biopsy followed by surgery.
• Adjuvant therapy (treatment given after surgery to increase the chances of a cure) that may include:
  • Radiation therapy to the lymph nodes near the breast and to the chest wall after a modified radical mastectomy.
  • Systemic chemotherapy with or without hormone therapy.
  • Hormone therapy.
• Clinical trials.

Treatment of stage IIIB and inoperable stage IIIC breast cancer may include:

• Systemic chemotherapy.
• Systemic chemotherapy followed by surgery (breast-conserving surgery or total mastectomy), with lymph node dissection followed by radiation therapy.
• Additional systemic therapy (chemotherapy, hormone therapy, or both).
• Clinical trials.

Treatment of stage IV or metastatic breast cancer may include the following:

• Hormone therapy and/or systemic chemotherapy.
• Radiation therapy and/or surgery for relief of pain and other symptoms.
• Clinical trials.

Other types of breast cancers

• Triple-negative breast cancer. Usually IDCs, whose cells lack certain receptors and tend to grow and spread more quickly than other types of breast cancer. Breast cancers with these characteristics tend to occur more often in younger women and in African-American women.
• Mixed tumors. Contain a variety of cell types, such as invasive ductal cancer combined with invasive lobular breast cancer.
• Medullary carcinoma. This infiltrating breast cancer has a rather well-defined boundary between tumor tissue and normal tissue.
• Metaplastic carcinoma. Also known as carcinoma with metaplasia, is a very rare type of invasive ductal cancer that includes cells that are normally not found in the breast, such as cells that look like skin cells or cells that make bone.
• Mucinous carcinoma. Also known as colloid carcinoma, this rare type of invasive breast cancer is formed by mucus-producing cancer cells.
• Paget disease. This breast cancer starts in the breast ducts and spreads to the skin of the nipple and then to the areola, the dark circle around the nipple. Paget disease is almost always associated with either DCIS or IDC.

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Not all breast cancer is found through mammography. The most common symptoms of breast cancer are:

• A change in the look or feel of the breast
• A change in the look or feel of the nipple

Other breast cancer symptoms may include:

• Lump, hard knot or thickening
• Swelling, warmth, redness or darkening
• New pain in one spot that doesn't go away
• Spontaneous nipple discharge

Inflammatory breast cancer symptoms

Symptoms of inflammatory breast cancer (IBC) may seem like an infection — redness, swelling and warmth — without a distinct lump in the breast. Other symptoms of IBD can include:

• Red, pink, reddish purple or bruised look to the skin
• Skin that appears pitted or to have ridges
• Breast heaviness
• Burning
• Aching
• Increase in breast size
• Tenderness
• Inverted nipple
• Swollen lymph nodes

Symptoms of IBC usually develop quickly — over a period of weeks or months. Cancer cells blocking the lymph vessels in the skin cause the redness and warmth. Changes in the skin's appearance signal a buildup of fluid.

The same symptoms may also be signs of other conditions such as infection, injury, or other types of cancer. It is important for women experiencing any of these symptoms to see their doctor.

Male breast cancer symptoms

In men, the most common symptoms of breast cancer are a change in the look or feel of the breast, a change in the look or feel of the nipple and nipple discharge. Possible signs of breast cancer to watch for in men include:

• A lump or swelling, which is usually (but not always) painless
• Skin dimpling or puckering
• Nipple retraction (turning inward)
• Redness or scaling of the nipple or breast skin
• Discharge from the nipple

These changes aren't always caused by cancer. For example, most breast lumps in men are due to gynecomastia (a harmless enlargement of breast tissue). Any breast changes are a reason to speak to Penn Medicine cancer specialist.

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Staging systems provide doctors with a common language for describing tumors. After cancer is first diagnosed, a series of tests are used to investigate the extent of the cancer and to see whether it has spread to other parts of the body from where it started. Staging is a way of recording the size and growth of a cancer, and determining the plan for treatment. By understanding the stage of their cancer, patients can make informed decisions about their treatment.

There are five stages of breast cancer:

• Stage 0. This is the earliest stage of non-invasive breast cancer.
• Stage I. The cancer is relatively small and contained where it started.
• Stage II. The cancer is localized, but the tumor is larger than in stage I and lymph nodes close to the original site may contain cancer cells.
• Stage III. The cancer is larger and there are cancer cells in the lymph nodes in the area.
• Stage IV. The cancer has spread (metastasized) from where it started to other organs, such as the liver, bones or lungs.

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At Penn Medicine, breast cancer is treated at the Abramson Cancer Center, home of the Rena Rowan Breast Cancer Center, and at the Joan Karnell Cancer Center, home of the Integrated Breast Center at Pennsylvania Hospital. Researchers at Penn continue to identify new detection methods, develop new therapies and improve the quality of life for women with breast cancer. Both centers have been granted full, three-year accreditation by the National Accreditation for Breast Centers. The accreditation recognizes the centers' commitment to offering patients every advantage in their breast disease care.

The Abramson Cancer Center's NCI-approved breast cancer research program is a leader in new detection techniques and clinical trials for breast cancer.

Penn brings together investigators from diverse disciplines and focuses their collective energies on understanding, preventing and treating breast cancer. This combined effort has enabled research advances to be used more quickly benefit patients and has made Penn a leader in breast cancer research.

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Following the guidelines for early detection improves the chances that breast cancer can be diagnosed at an early stage and treated successfully. The American Cancer Society recommends:

• Screening mammograms annually for women age 40 and older.
• Clinical breast exam (CBE) for women in their 20s and 30s as part of a regular exam by a health professional, at least every three years. After age 40, women should have a breast exam by a health professional every year.
• Breast self exam (BSE) is an option for all women starting as early as in their 20s.
• Annual mammogram and breast MRI for women at high risk for breast cancer.

The goal of breast cancer screenings, such as mammograms, is to find breast cancers before they spread. Breast cancers that can be felt tend to be larger and are more likely to have already spread beyond the breast. Breast cancers found during screening exams are more likely to be small and still confined to the breast. The size of a breast cancer and how far it has spread are important factors in predicting the prognosis for women with breast cancer.
Women at high risk (greater than 20 percent lifetime risk based on family history) should get an MRI and a mammogram every year. Women at moderately increased risk (15 to 20 percent lifetime risk based on family history) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is less than 15 percent.

MRI screening is done in addition to a screening mammogram. Although an MRI is a more sensitive test, it can return false positive results or miss some cancers that a mammogram does detect.

For most women at high risk, screening with MRI and mammograms should begin at age 30 years and continue for as long as a woman is in good health. Because the evidence is limited regarding the best age at which to start screening, this decision should be based on shared decision-making between patients and their health care providers, taking into account personal circumstances and preferences.

If something suspicious is found during a screening exam, one or more breast tools can help doctors find out if breast cancer is present. If cancer is confirmed, the stage of the cancer is then determined. Staging refers to how far the cancer has spread to nearby tissue or organs.

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If something suspicious is found during a screening exam, physicians at Penn Medicine will use one or more of the following tests to find out if breast cancer is present. Tests include:

• Medical history and physical exam. The breasts are thoroughly examined for any lumps or suspicious areas and to feel their texture, size, and relationship to the skin and chest muscles. Any changes in the nipples or the skin of the breasts will be noted. The lymph nodes in the armpit and above the collarbones may be palpated, because enlargement or firmness of these lymph nodes might indicate spread of breast cancer.
• Imaging tests. Pictures of the inside of the body can help find out whether a suspicious area might be cancerous, to learn how far cancer may have spread, and to help determine if treatment is working.
• Diagnostic mammograms. Although mammograms are mostly used for screening, they can also be used to examine the breast of a woman who has a breast problem. This can be a breast mass, nipple discharge, or an abnormality that was found on a screening mammogram. In some cases, special images known as magnification views are used to make a small area of abnormal breast tissue easier to evaluate.
• Digital mammograms. Digital mammograms are the same as standard mammograms in that X-rays are used to produce an image of the breast. The differences are in the way the image is recorded, viewed by the doctor, and stored. Standard mammograms are recorded on large sheets of photographic film. Digital mammograms are recorded and stored on a computer. After the exam, the doctor can look at them on a computer screen and adjust the image size, brightness, or contrast to see certain areas more clearly. Digital images can also be sent electronically to another site for a remote consult with breast specialists. All of Penn's imaging facilities use digital mammography.
• Computer-aided detection and diagnosis (CAD). Over the past two decades, CAD has been developed to help radiologists detect suspicious changes on mammograms. This can be done with standard film mammograms or with digital mammograms.
• Magnetic resonance imaging (MRI) of the breast. MRI scans use radio waves and strong magnets instead of X-rays. It's important that MRI scans of the breast be done on an MRI machine specially adapted for breast views.
• Breast ultrasound. Uses sound waves to image the breast. This test is painless and does not expose patients to radiation. It is used primarily to target a specific area of concern found on a mammogram or a lump found during a physical exam.
• Biopsy. A sample of the suspicious area is removed and viewed under a microscope when mammograms and other tests find a breast change that is possibly cancer. A biopsy is the only way to tell if cancer is really present.

Diagnostic Surgery/Biopsy

A biopsy is a diagnostic surgical procedure in which a tiny bit of the breast tumor is removed and examined under a microscope.

Penn Medicine surgeons perform several different types of biopsies based the amount of tissue being removed. Some biopsies use a very fine needle, while others use thicker needles or even require a small surgical procedure to remove more tissue. The breast cancer team decides which type of biopsy to use depending on the particular breast mass.

• Fine needle aspiration biopsy. Fine needle aspiration (FNA) is the least invasive method of biopsy and it usually leaves no scar. An injection of local anesthesia numbs the breast before the surgeon or radiologist uses a thin needle with a hollow center to remove a sample of cells from the suspicious area. In many cases, the doctor can feel the lump and guide the needle to the right place. If the lump cannot be felt, imaging studies such as ultrasound or mammogram are used to guide the needle to the right location.
• Core needle biopsy. Core needle biopsy uses a larger hollow needle than fine needle aspiration does to remove several cylinder-shaped samples of tissue from the suspicious area. This type of biopsy is frequently called a vacuum-assisted core biopsy. In most cases, the needle is inserted about three to six times so that the doctor can get enough samples. If the lesion cannot be felt through the skin, the surgeon or radiologist can use an image-guided technique such as ultrasound-guided biopsy or stereotactic needle biopsy. A small metal clip may be inserted into the breast to mark the site of biopsy in case the tissue proves to be cancerous and additional surgery is required. This clip is left inside the breast and is not harmful to the body. If the biopsy leads to more surgery, the clip will be removed at that time. If no cancer is found, the clip serves as a sign in future mammograms that tells the radiologist a breast biopsy was performed.
• Incisional biopsy. Incisional biopsy is more like regular surgery, in which the surgeon uses a scalpel to remove a piece of the tissue for examination. The doctor may recommend incisional biopsy if a needle biopsy is inconclusive or if the suspicious area is too large to sample easily with a needle. Prior to the biopsy, the surgeon may use imaging studies to place a small wire into the area of concern. The wire is used as a guide in determining the right tissue for the biopsy.
• Excisional biopsy. Excisional biopsy is the most involved form of biopsy, using surgery to remove the entire area of suspicious tissue from the breast.

In addition to offering quick results without significant discomfort and scarring, both fine needle aspiration and core needle biopsy give patients the opportunity to discuss treatment options with their doctor before having surgery. In some cases, needle biopsy can be performed right in the doctor's office. However, because needle biopsy takes only a small sample of tissue there is a higher risk of a false negative result, suggesting that cancer is not present when it really is.

Incisional and excisional biopsies are more invasive than needle biopsies. They leave a scar and may require a longer time to recover. As with needle biopsy, there is some possibility that incisional biopsy can return a false negative result. However, the results are available fairly quickly. Excisional biopsy is the surest way to establish a definite diagnosis without getting a false negative result. Having the entire lump removed can also provide some patients with additional some peace of mind.

Breast MRI

Unlike mammography, which uses X-rays to examine breast tissue, magnetic resonance imaging (MRI) scans of the breast use radio waves and strong magnets. During the scan, the energy from the radio waves is absorbed and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a very detailed image of the breast.

MRI scans present detailed images of the breast and help Penn cancer specialists accurately diagnose and locate breast tumors. Breast MRI has a number of different uses for breast cancer, including:

• Screening women known to be at higher than average risk for breast cancer, either because of a strong family history or a gene abnormality.
• Gathering additional information about an area of suspicion found on a mammogram or ultrasound.
• Screening for women with dense breast tissue.
• Monitoring for cancer recurrence after treatment.
• Ruling out other lesions once breast cancer is diagnosed.

Positron Emission Tomography (PET) Scan

PET scans can help cancer specialists at Penn precisely find cancer cells in the body. PET scans create computerized images of chemical changes, such as metabolism, that take place in tissue. This helps locate breast cancer cells as they have a higher metabolism than other tissues in the body.

PET scans are not used to screen for breast cancer, but once breast cancer has been diagnosed, PET scans are used to determine:

• If the cancer has spread to lymph nodes.
• If the cancer has spread to other parts of the body and where it has spread.
• If metastatic breast cancer is responding to treatment.

When appropriate, Penn radiation oncologists use PET for planning radiation therapy. Penn has one of the few radiation oncology departments in the country with a dedicated PET/CT scanner used solely for the purpose of planning radiation treatments The combined matching of a CT scan with PET images improves the ability to discriminate normal from abnormal tissues and helps radiation oncologists check the effectiveness of radiation treatments on the cancer cells.

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An important part of diagnosing and treating breast cancer at Penn Medicine is staging. Staging is the process of finding out how much cancer there is and where it is located. This information is used to plan cancer treatment and develop a prognosis.

Staging is a way to make sure patients get the best possible treatment. For most cancers, the stage is based on three main factors:

• Size of the tumor and whether or not it has grown into nearby areas (T)
• If the cancer has spread to nearby lymph nodes (N)
• If the cancer has spread to distant areas of the body (M)

Once the TNM are determined, a stage is assigned to the breast cancer:

• Stage 0. Ductal carcinoma in situ (DCIS), the earliest form of breast cancer is a non-invasive condition. The cancer cells are still within a duct and have not invaded deeper into the surrounding fatty breast tissue. Lobular carcinoma in situ(LCIS) is sometimes also classified as stage 0 breast cancer, but most oncologists believe it is not a true breast cancer. 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. In LCIS, abnormal cells grow within the lobules or milk-producing glands, but they do not penetrate through the wall of these lobules. Paget disease of the nipple (without an underlying tumor mass) is also stage 0. In all cases, the cancer has not spread to lymph nodes or distant sites.
• Stage I. The tumor is 2 cm (about 3/4 of an inch) or less across and has not spread to lymph nodes or outside the breast.
• Stage IIA. One of the following applies and the cancer hasn't spread to distant sites:
• The tumor is 2 cm or less across (or is not found) and has spread to one to three axillary lymph nodes, with the cancer in the lymph nodes larger than 2 mm across.
• The tumor is 2 cm or less across (or is not found) and tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.
• The tumor is 2 cm or less across (or is not found) and has spread to one to three lymph nodes under the arm and to internal mammary lymph nodes (found on sentinel lymph node biopsy).
• The tumor is larger than 2 cm across and less than 5 cm but hasn't spread to the lymph nodes.
• Stage IIB. One of the following applies and the cancer hasn't spread to distant sites:
• The tumor is larger than 2 cm and less than 5 cm across. It has spread to one to three axillary lymph nodes and/or tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.
• The tumor is larger than 5 cm across but does not grow into the chest wall or skin and has not spread to lymph nodes.
• Stage IIIA. One of the following applies and the cancer hasn't spread to distant sites:
• The tumor is not more than 5 cm across (or cannot be found). It has spread to four to nine axillary lymph nodes, or it has enlarged the internal mammary lymph nodes.
• The tumor is larger than 5 cm across but does not grow into the chest wall or skin. It has spread to one to nine axillary nodes, or to internal mammary nodes.
• Stage IIIB. The tumor has grown into the chest wall or skin but hasn't spread to distant sites, and one of the following applies:
• It has not spread to the lymph nodes.
• It has spread to one to three axillary lymph nodes and/or tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.
• It has spread to four to nine axillary lymph nodes, or it has enlarged the internal mammary lymph nodes.
• Inflammatory breast cancer is classified as stage IIIB unless it has spread to distant lymph nodes or organs, in which case it is stage IV.
• Stage IIIC. The tumor is any size (or can't be found), hasn't spread to distant sites and one of the following applies:
• Cancer has spread to 10 or more axillary lymph nodes.
• Cancer has spread to the lymph nodes under the clavicle (collar bone).
• Cancer has spread to the lymph nodes above the clavicle.
• Cancer involves axillary lymph nodes and has enlarged the internal mammary lymph nodes.
• Cancer has spread to four or more axillary lymph nodes, and tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.
• Stage IV. The cancer can be any size and may or may not have spread to nearby lymph nodes. It has spread to distant organs or to lymph nodes far from the breast. The most common sites of spread are the bone, liver, brain or lung.

A Penn cancer physician can answer any questions about the stage of cancer and what it might mean regarding prognosis and treatment.

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Breast surgeons at Penn Medicine deal almost exclusively with breast cancer and disorders of the breast. They have popularized the concepts of breast conserving therapy and are pioneering the use of vaccines and immune-based therapies for the treatment of breast cancer. Penn is also a leader in the use of oncoplastic surgery, using techniques to remove the tumor and preserve or restore the breast's shape or appearance at the same time.

By constantly working to better understand the molecular characteristics of breast cancer, Penn's surgeons help develop new therapeutic options for treatment. Both independently and as part of the Abramson Cancer Center and the Joan Karnell Cancer Center, Penn's breast surgeons have been involved with research endeavors that have changed the national standards with regard to the management of breast cancer

Surgery is also used to check the lymph nodes under the arm for cancer spread. Penn breast surgeons have a great deal of experience performing sentinel lymph node biopsy and an axillary (armpit) lymph node dissection.

Breast reconstruction can be done at the same time as the mastectomy or done later. Penn's plastic surgeons are leaders in the field of reconstructive surgery, including reconstructive microsurgery to improve appearance and function.

Breast-conserving Surgery

Breast-conserving surgery removes only the part of the breast affected by cancer and a surrounding margin of normal tissue. How much tissue is removed depends on the size and location of the tumor and other factors. Penn surgeons are leaders in the use of oncoplastic surgery, which uses techniques to remove the tumor and preserve or restore the breast's shape or appearance at the same time, such as skin-sparing mastectomy, and nipple sparring mastectomy.

Partial mastectomy, quadrantectomy and lumpectomy are all types of breast-conserving surgery. If cancer cells are found at any of the edges of the tissue removed, it is said to have positive margins. When no cancer cells are found at the edges of the tissue, it is said to have negative or clear margins. The presence of positive margins means that that some cancer cells may have been left behind after surgery. If the pathologist finds positive margins in the tissue removed by breast-conserving surgery, the surgeon may need to go back and remove more tissue. If the surgeon can't remove enough breast tissue to get clear surgical margins, a total mastectomy may be needed.

Radiation therapy is often given after surgery and small metallic clips (visible on X-rays) may be placed inside the breast during surgery to mark the area for the radiation treatments.

If chemotherapy is to be given as well, radiation is usually delayed until the chemotherapy is completed.

Mastectomy involves removing all of the breast tissue, sometimes along with other nearby tissues. In a simple or total mastectomy, the surgeon removes the entire breast, including the nipple, but does not remove underarm lymph nodes or muscle tissue from beneath the breast.

A modified radical mastectomy is a simple mastectomy plus removal of axillary (underarm) lymph nodes.

A radical mastectomy is an extensive operation where the surgeon removes the entire breast, axillary lymph nodes, and the pectoral (chest wall) muscles under the breast. This surgery was once very common, but a modified radical mastectomy has proven to be just as effective without the disfigurement and side effects of a radical mastectomy. Radical mastectomy may still be done for large tumors that are growing into the pectoral muscles under the breast.

For some women considering immediate breast reconstruction, a skin-sparing mastectomy can be done. Selected patients with small breasts and small, favorable, peripherally located tumors, or patients with small breasts undergoing prophylactic mastectomy, nipple-sparing mastectomy with immediate reconstruction is a cosmetically excellent option.

Choosing Between Lumpectomy and Mastectomy

Many women with early-stage cancers can choose between breast-conserving surgery and mastectomy. A small number of women having breast-conserving surgery may not need radiation while a small percentage of women who have a mastectomy will still need radiation therapy to the breast area.

Chemotherapy may be given before the surgery to shrink the tumor and reduce the amount of tissue that needs to be removed during surgery. Chemotherapy treatment given before surgery is called neoadjuvant therapy.

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

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Breast reconstruction is a surgical procedure to recreate the shape and appearance of the breast, usually done as part of a mastectomy, surgery to remove an entire breast as treatment for breast cancer.

There are two types of breast reconstruction:

• Natural tissue
• Breast implant

Most insurance providers cover the cost of breast reconstruction after mastectomy.

Penn plastic surgeons are highly skilled and perform the most sophisticated types of breast reconstruction on a daily basis. They provide patients with options for breast reconstruction and work with the surgical, medical, and radiation oncologists in providing the safest and most appropriate surgical plan to restore the body and to help patients heal.

Many women consult with a Penn reconstructive plastic surgeon soon after being diagnosed with breast cancer. This allows plastic surgery to be an integral part of the cancer treatment team.

Women who previously had a mastectomy may still be able to restore a more natural appearance. They should speak with a Penn plastic surgeon about reconstructive surgery to determine their options.

The timing of breast reconstruction is another important factor to consider. Breast reconstruction can occur at either the time of mastectomy or at some point after the initial mastectomy is completed. These two time frames are referred to as immediate or delayed reconstruction.

Most surgeons agree that the aesthetic result and technical ease are improved in an immediate breast reconstruction compared to delayed reconstruction. Surgeons at Penn Medicine typically utilize skin-sparing mastectomies (SSM). This method of mastectomy allows for satisfactory local control of the breast cancer while preserving the breast boundaries. When breast reconstruction is performed in the immediate setting, there is no scar tissue to overcome and the skin envelope helps maintain the natural borders of the breast. By preserving the natural skin brassiere, the reconstruction is more straightforward and leads to a reconstruction that is more symmetric to the opposite breast.

Natural Tissue Reconstruction

In natural tissue reconstruction, Penn plastic surgeons move tissue from the belly or back of the patient to the breast. Though this surgery is more extensive, it can provide a great emotional benefit and is often performed during the same operation as the mastectomy.

The best option is an autologous tissue reconstruction using tissue from the patient's lower abdomen. The moved tissue is kept alive on a muscle or microsurgery can be used to reattach blood vessels to keep the transplanted tissue alive. Patients can expect to spend four to five days in the hospital for natural tissue reconstruction.

Patients desiring autologous tissue reconstruction from the abdomen must have sufficient lower abdominal tissue available to reconstruct the breast. If the lower abdomen is not a sufficient donor site, or if previous surgery eliminates the potential use of this tissue, a number of alternative flaps from other parts of the body have been developed as additional options.

Penn plastic surgeons are among the most skilled in the country in performing autologous breast reconstruction. As in all procedures, there are complications associated with autologous breast reconstruction, including total flap failure or partial flap failure. Total flap failure is a rare complication occurring in less than 1 percent of Penn patients.

Breast Implant Reconstruction

Not every woman has the option of using her own tissue. In those cases, breast implants or tissue expanders are used in breast reconstruction. Saline and silicone implants are quite safe and present unique benefits to cancer patients. As a leader in breast reconstruction, Penn is participating in a national study analyzing the use of silicone breast implants in breast reconstruction.

For many women who chose implant reconstruction, tissue expanders are initially placed underneath the muscles of the chest. The expanders undergo several inflations using saline to create a sizable'pocket' for the subsequent implant. Once the appropriate'pocket' has been achieved, the patient returns to the operating room for removal of the tissue expander in exchange for a silicone or saline implant. Both types of implants are available, and to date, no study has documented a cause and effect relationship between silicone or saline implants and systemic illness.

Recently, there has been a movement to reduce the number of procedures needed for implant reconstruction by eliminating the need for tissue expansion. This can be achieved with post-operative, adjustable, saline implants that function as both an expander and implant.

The principle benefit of using implants for breast reconstruction is in the ease of reconstruction and limiting the surgical site to the chest. Implant reconstruction does, however, have both aesthetic and functional downsides. The implant can be felt and is often visible through the breast skin. An implant reconstruction is also less natural in shape and consistency when compared to a natural breast.

Patients can expect to stay in the hospital one to two nights after breast implant reconstructive surgery. Women who have been given tissue expanders or breast implants most often experience discomfort for about a week. They can also expect two or three days of tenderness after each expansion.

Women who have had their own tissue used in the reconstruction can expect to have discomfort around their breasts and where the tissue was removed for two to three weeks.

Reconstructive surgery has risks, but patients can help prevent complications by carefully following their physician's instructions both before and after surgery and understanding the potential risks and complications. Infection is the most common postoperative implant-related complication.

Restoration of the breast following mastectomy has become an integral part of the holistic treatment of breast cancer. Reconstruction of the breast can happen at the time of mastectomy or at a later date as a separate operation depending on a variety of factors. These may include the women's wishes, desires and goals, the type and size of tumor, the possible need for post-operative radiation therapy or chemotherapy. The surgeon, oncologist, and plastic surgeon all assist the patient in making this decision.

The overall goals of breast reconstruction are to achieve a normal and symmetric silhouette, to limit patient morbidity, and to avoid the need for an external prosthesis.

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Penn Radiation Oncology has an international reputation for developing alternatives to mastectomy in the treatment of early stage breast cancer. Penn radiation oncologists were pioneers in providing radiation therapy following lumpectomy as an alternative to mastectomy. They work side-by-side with their surgical and medical colleagues to conduct pilot studies of locally advanced breast cancer.

Radiation therapy is used to destroy any microscopic cancer cells that may still be present in the breast/chest wall or regional lymph nodes following complete surgical removal of all visible cancer. Radiation is almost always recommended after lumpectomy and may also be advised after mastectomy for some women.

Penn radiation oncologists are experts in using multiple advanced radiation techniques to treat all tissues at risk of harboring residual microscopic breast cancer cells after surgery while minimizing exposure to the adjacent normal tissues such as the heart and the lung, thereby minimizing the risks of short and long-term side effects from radiation therapy.

Accelerated Partial Breast Irradiation (APBI)

Patients who have been diagnosed with an early-stage breast cancer (stage 0, I or II), with limited or no lymph node involvement, and a tumor size smaller than 3 cm (about the size of a walnut), may be eligible to receive a treatment option called APBI. APBI can be delivered using either brachytherapy or external beam radiation delivered by a linear accelerator.

For brachytherapy, a catheter is placed into the lumpectomy cavity by the patient's breast surgeon. The radiation is then delivered by temporary insertion of a radioactive source into the catheter, generally twice a day for one week. There are a number of catheters from different manufacturers that can be used to help deliver breast brachytherapy. Two of the more commonly used devices are the MammoSite® and MammoSite® ML catheters.

Conformal Radiation Therapy

The imaging technology used by radiation oncologists at Penn Medicine can be used to shape the radiation treatment beam to the shape of the region at risk of harboring microscopic cancer cells. Known as conformal radiation therapy, this technology gives doctors more control to treat the tissues that may contain cancer cells while avoiding the healthy normal tissues as much as possible.

In conformal radiation, a special computer uses CT imaging scans to create 3-D maps of the region being targeted for treatment (breast or chest wall and, in some cases, the regional lymph node areas). The system permits delivery of radiation from several directions and the beams can then be shaped, or conformed, to match the shape of the target volume. Conformal radiation therapy limits radiation exposure to nearby healthy tissue as well as the tissue in the beam's path.

Image-guided Radiation Therapy (IGRT)

In image-guided radiation therapy (IGRT), the linear accelerators that deliver radiation are equipped with imaging technology that take pictures of the region being treated immediately before or even during the time radiation is delivered. The purpose of IGRT is to ensure accurate delivery of the radiation therapy on a daily basis.

Specialized computer software is used to compare these images taken prior to treatment to images taken during the CT-simulation to establish that the patient is in the correct treatment position. Necessary adjustments can then be made to the patient's position and/or the radiation beams to more precisely target radiation at the breast cancer and avoid the healthy surrounding tissue.

Imaging used in IGRT includes:

• Computed tomography (CT)
• Magnetic resonance imaging (MRI)
• Positron emission tomography (PET)
• X-rays

Intensity-modulated Radiation Therapy (IMRT)

Intensity-modulated radiation therapy (IMRT) is used to improve the evenness of the radiation dose distribution with the breast, allowing women to complete their course of radiation therapy with less skin irritation compared with conventional radiation techniques. The even radiation dose distribution achieved by IMRT may also improve the long-term appearance of the irradiated breast.

MammoSite®

MammoSite is a targeted radiation therapy treatment in which a small, soft balloon attached to a thin catheter is placed inside the lumpectomy cavity through a small incision in the breast. During therapy, the portion of the catheter that remains outside of the breast is connected to a computer-controlled high-dose rate machine that inserts a radiation"seed" to deliver the therapy to the area where cancer is most likely to recur.

Once the therapy is complete, the seed is removed and the catheter unplugged.

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Penn medical oncologists are experts in treating breast cancer with chemotherapy and other approaches, including hormonal therapy. They lead the way in developing new targeted therapies such as the use of monoclonal antibodies, vaccines and immune-based therapies. The Abramson Cancer Center's NCI-funded and approved breast cancer research program and active clinical trials group have pioneered some of the standard treatments used around the world to treat breast cancer.

Many cancer treatments are used in combination to lower the risk that the cancer will come back. Adjuvant therapy, treatment given after surgery, may include chemotherapy, radiation, hormone therapy, targeted therapy, immunotherapy or vaccine therapy.

Chemotherapy

Penn medical oncologists have a great deal of experience in the use of chemotherapy as part of an overall breast cancer treatment program and in chemotherapy research. Chemotherapy uses drugs to kill cancer cells.

Hormone Therapy

Hormone therapy is another form of breast cancer treatment. It is most often used as adjuvant therapy to help reduce the risk of cancer recurrence after surgery. It is also used to treat cancer that has come back after treatment or has spread. Estrogen promotes the growth of about two out of three breast cancers – those containing estrogen receptors (ER-positive cancers) and/or progesterone receptors (PR-positive cancers). Because of this, several approaches to blocking the effect of estrogen or lowering estrogen levels are used to treat ER-positive and PR-positive breast cancers. Hormone therapy does not help patients whose tumors are both ER- and PR-negative.

Immunotherapy

Immunotherapy is designed to repair, stimulate, or enhance the immune system's response to breast cancer cells. Penn medical oncologists are experts in the use of immunotherapy to stimulate the immune system to work harder, recognizing the difference between healthy cells and breast cancer cells, and eliminating the cancer cells.

Vaccine Therapy

Cancer vaccines are designed to teach the immune system to attack and destroy cancer cells. Normally, when foreign cells such as a bacterial infection enter the body, the immune system responds to the invasion and clears the body of the foreign cells. Unlike infectious cells, cancer cells are not recognized as foreign by the body. Instead, the immune system thinks the cancer cells are part of the normal body and do not mount an immune response against the cancer. Cancer vaccines allow the immune system to recognize cancer cells as foreign and, therefore, trigger the immune system to attack the cancer cells.

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At the end of treatment, breast cancer patients should schedule a survivorship visit with their oncologist and nurse practitioner. At this time, patients are provided with a summary of the treatment received as well as a plan for follow-up care.

Long-term breast cancer survivors should speak to their oncologist and nurse practitioner about scheduling a one-time survivorship-focused consultation with a nurse practitioner or physician. Annual or more frequent follow-up appointments are also available.

Penn cancer providers work one-on-one with patients to develop survivorship care plans. Since every cancer is unique, the plans are tailored to the patients.

The survivorship care plan includes information on:

• Potential long-term or late side effects of cancer treatment, the symptoms and treatment.
• Recommendations for cancer screening for disease recurrence or a new cancer.
• Psychosocial effects, including relationships and sexuality.
• Planning follow-up visits.

A survivorship care plan encourages patients to review the information with their healthcare team and become active participants in their follow-up care.

Penn also offers breast cancer patients a number of support programs and groups to enhance their survivorship care plans.

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Penn Medicine's Living Well After Cancer™ Program is a nationally recognized program that focuses on issues facing cancer survivors. In 2007, the Abramson Cancer Center was invited to join the LIVESTRONG ™ Survivorship Center of Excellence Network. The program focuses on survivorship, a distinct phase of care.

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Long-term breast cancer survivors can speak to their Penn oncologist and nurse practitioner about scheduling a survivorship-focused consultation with a nurse practitioner in the Breast Cancer Survivors' Clinic at the Rena Rowan Breast Center. Annual or more frequent follow-up appointments are also available.

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Prescription for Living at Pennsylvania Hospital is a survivorship care plan that provides patients with a summary of their cancer diagnosis and treatment. With more people than ever surviving cancer, the Joan Karnell Cancer Center at Pennsylvania Hospital created Prescription for Living to provide patients with the information they need to stay healthy after their cancer treatment has ended.

Treatment Summary

Every patient receives a treatment summary specific to their individual case when they complete treatment. These detailed reports document the diagnosis, including cancer stage, specific types of treatment as well as any other medical concerns that may arise as the result of the disease and its treatment. A copy is also sent to primary care providers and other specialists designated by patients.

Follow-Up Schedule

It is important that patients understand and adhere to the follow-up developed for them. This individualized schedule helps the team to monitor patients' health and observe any long-term side effects of treatment.

Late Effects

Not all cancer survivors experience late effects, or issues that arise later as a result of treatment or disease. About two-thirds of survivors experience physical or psychosocial effects of chemotherapy or radiation that persist or develop more than five years from the time of diagnosis. It's important for patients to know about these risks so their health can be appropriately monitored. The cancer care team discusses any pertinent late effects with patients and together develops a plan to monitor and treat late effects.

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