Proficiencies in Acıbadem Breast Health

Treatment Options by Condition of Disease

Surgical procedures are first preferred for treatment of breast cancer diagnosed at early stages. Generally, surgical management is immediately followed by systemic treatments, such as chemotherapy and/or hormone therapy. Radiotherapy is frequently preferred in treatment of cancer to kill cancer cells and destroy tumors.

Treatment Methods of Breast Cancer

Various methods are used to manage breast cancer. Although treatment modalities vary depending on course of disease, these are surgery, medication therapy (chemotherapy), hormonotherapy (treatments with hormone drugs), radiotherapy and biologic treatments to list a few. The first-line treatment is dictated by clinical stage of the disease.

Cerrahiye Hangi Durumlarda Başvuruluyor?

Acıbadem Kayseri Hospital Genel Cerrahi Uzmanı Prof. Dr. Can Küçük; "Meme Kanseri" üzerine soruları cevaplıyor.

Surgery is the first option for breast cancers diagnosed at early stages. Considering surgical approach, either breast tumor is removed, but a safety zone of healthy tissue is left or entire breast is excised. Moreover, some lymph nodes are dissected to understand whether tumor has spread to armpits or not..

First, stage of disease is determined following the surgery to decide extra treatments (radiotherapy, hormone therapy, chemotherapy) that are required.

Today, very successful outcomes are obtained in many patients thanks to advancements in surgery techniques and adjunctive therapies.

Is Entire Breast Removed?

In the past, it was thought that there was no option other than removal of entire breast (mastectomy) and complete dissection of axillary lymph nodes. However, it is, nowadays, preferred only for a couple of patients, if the condition is diagnosed at early stages.

For one out of every two patients, it is possible to spare the breast by removing the tumor followed by breast radiotherapy. Breast-sparing treatment does not significantly differ from total removal of breast in selected patients.

Breast Surgery

Considering treatment of breast cancer, surgery is the first option for breast cancers diagnosed at early stages. Considering surgical approach, either breast tumor is removed, but a safety zone of healthy tissue is left or entire breast is excised. Moreover, some lymph nodes are dissected to understand whether tumor has spread to armpits or not. First, stage of disease is determined following the breast surgery to decide extra treatments (radiotherapy, hormone therapy, chemotherapy) that are required.

Today, very successful outcomes are obtained in treatment of breast cancer for many patients thanks to advancements in surgery techniques and adjunctive therapies.

Memede Bir Kitle Tespit Edildiğinde Mutlaka Alınmalı Mıdır?

Acıbadem Bursa Hospital, Genel Cerrahi Uzmanı Prof. Dr. Abdullah Zorluoğlu, Kanser üzerine soruları yanıtlıyor.

Breast-sparing Surgery

Patients with breast cancer die due to systemic recurrence, also called metastasis, rather than local relapses in breast. In this sense, surgery techniques that focus on removal of tumor through a breast-sparing approach are preferred over total removal of breast in selected cases with single tumor. In breast sparing surgery, tumor tissue is removed along with approximately 1- to 2-cm healthy breast tissue surrounding the tumor (large excision, tumorectomy, and lumpectomy).

Other techniques that enable larger removal of the diseased part in breast are called “quadrantectomy” or “partial mastectomy”.

Non-palpable lesions which are considered malignant and marked with wire under mammography or ultrasound scans are removed under guidance of wire or ROLL (Radionuclide-Guided Occult Lesion Localization) technique; and next, X-ray is scanned to confirm removal of the lesion.

Meme Kanserinin Cerrahi Tedavisinde Memenin Tümünün Alınması Ne Zaman Gerekli Oluyor?

Acıbadem Maslak ve Bakırköy Hastaneleri Genel Cerrahi Uzmanı Prof. Dr. Cihan Uras, meme kanserinin cerrahi tedavisinde memenin tümünün alınmasıyla ilgili açıklama yapıyor..

Who are good candidates?

In treatment of breast cancer, breast-sparing surgery should generally be performed in selected patients: the disease is at early stage (stage I-II) and tumor/breast ratio is appropriate; there is single-focus small tumor; and postoperative radiotherapy is planned for the patient. Annual rate of relapse in same breast is 0.5-1 percent following breast-sparing surgery, but it may vary according to characteristics of tumor.

What should be taken into account?

In management of breast cancer, it is necessary to ensure that patients are informed before surgery, radiotherapy may be required and the patient will present for follow-up visits. It is essential to follow up patients carefully for a long time. If patient will receive chemotherapy after surgery, chemotherapy is followed by radiotherapy.

Treatment is planned through multidisciplinary approach for breast cancer. Physicians of general surgery, radiology, pathology, medical oncology and radiation oncology clinics work in cooperation through a multidisciplinary approach to plan treatment of breast cancer. Considering treatment of breast cancer, patients are mostly examined first by a general surgeon. Another important aspect of treatment is to have patients evaluated by psychologists and psychiatrists before and after treatment..

Mastectomy

Although mastectomy (surgical removal of entire breast) had been widely used in the past, it is, nowadays, preferred for a large tumor and/or multi-focus tumors that involve breast diffusely, as breast-sparing surgery is not appropriate for latter cases.

Such surgeries may be performed in the form of “nipple sparing mastectomy” to preserve skin of breast in early stage tumors or if the tumor is located distant to the nipple.

Meme Kanserinin Cerrahi Tedavisinde Memenin Alınması Her Zaman Gerekli Mi?

Acıbadem Maslak ve Bakırköy Hastaneleri Genel Cerrahi Uzmanı Prof. Dr. Cihan Uras, Meme kanserinin cerrahi tedavisinde memenin alınması konusunda açıklama yapıyor.

Surgical Procedures for Armpits

Breast cancer most commonly spreads to lymph nodes of axillary fossa (armpit). In the past, removal of all axillary lymph nodes (axillary dissection) was preferred to stage the disease, determine involvement of axillary lymph nodes and ensure local control. However, side effects of this procedure, including but not limited to swollen arm (lymphedema), limited range-of-motion and deformity in shoulders, weakness of muscles in arms and numbness have steered research to novel modalities.

Recently, “Sentinel Lymph Node Biopsy Technique” was developed that implies removal of lymph nodes, which are most likely to be invaded by tumor cells.

In this technique, a radioactive substance is preoperatively injected into the location of tumor in breast. Following lymphoscintigraphy one day before the surgery or on the morning of surgery if it is scheduled to be performed in the afternoon, the lymph node(s) with high radioactive substance (tracer) activity are detected by a radioactive substance detector or counter, called gamma probe, and they are surgically removed and sent to pathology laboratory for relevant tests and examinations.

A blue dye can also be injected to the breast with tumor in the surgery. In this case, the blue stained lymph duct is identified and tracked to remove blue stained lymph node(s) that is/are called sentinel lymph node and the specimen is again sent to pathologist while the surgery continues. All axillary lymph nodes are removed, if sentinel lymph node is involved.

In case of negative biopsy result, the tissue is left untouched and lymph nodes are not dissected that are considered clean. Thus, certain side effects such as lymphedema, restricted range-of-motion in shoulder or numbed arm are very rare in patients, if only sentinel lymph node biopsy is performed.

However, these sentinel lymph nodes are subjected to special treatments and advanced staining techniques are performed for negative specimens. Consequently, a second surgery is considered and complementary axillary dissection is performed or in other words, all lymph nodes are dissected, if minimal involvement is detected in lymph nodes.

Axillary lymph nodes are involved less than 50 percent in T1/T2 tumors that are smaller than 5 cm. Therefore, sentinel lymph node biopsy should be performed for all T1/T2 cases, especially if clinical examination and/or ultrasound scan does not point to suspicion of axillary lymph node involvement.

Since studies on patients without any tumor in axillary lymph nodes could not reveal out a difference regarding axillary local recurrence in long-term outcomes of patients in groups of sentinel lymph node biopsy or axillary dissection, it is possible to mention that sentinel lymph node biopsy alone is the standard approach for clinically axilla-negative patients.

It refers to dissecting most of the axillary lymph nodes in case of axillary lymph node involvement. In such cases, some patients may experience certain complaints, such as swelling, numbness or tingling in arms secondary to dissection of lymph nodes.

Breast Reconstruction

Breast reconstruction is performed to restore natural form of the breast that is defective due to breast cancer. This point of view suggests that breast reconstruction should be deemed a reconstructive surgery, which implies restoration of a limb lost due to a disease, rather than a cosmetic surgery.

Plastic and reconstructive surgeons are also in the treatment team of breast cancer. Aforementioned physicians perform surgeries which restore breast of patients to the natural form, if required.

Surgeons can construct breasts which look very natural thanks to recent advancements in medicine.

Reconstruction of Breast Tissue

Selection of surgical technique and appropriate time of repair surgery are dictated by certain criteria. A series of factor play a role in the decision process, including but not limited to overall health of patient, age, body characteristics, features of mastectomy, whether radiotherapy is required or not, condition of other breast, preference of patient and experience and skills of the plastic surgeon.

Memenin Tümünün Alındığı Durumlarda Aynı Seansta Meme Yapabilmek Mümkün Mü?

Acıbadem Maslak ve Bakırköy Hastaneleri Genel Cerrahi Uzmanı Prof. Dr. Cihan Uras, memenin tümünün alındığı durumlarda aynı seansta meme yapımıyla ilgili bilgi veriyor.

There are two main types of breast implants: Ones filled with gel and ones with saline. Exterior surface is made of silicone membrane in both types of implants. Breast can be reconstructed directly by placing implants (in simultaneous reconstructions) or a “tissue expander” is placed to expand soft tissues of chest wall and next, it is removed to make a room for placement of breast implant. This method is preferred especially for late-stage reconstructions.

Reconstruction surgery with breast implant is technically a simple and short-lasting method. However, a foreign body is surgically placed into the body and these reconstructions may cause certain complications, such as infection, silicone leak or deflation of implant. Another adverse outcome of this technique is failure to create a natural look due to development of solid tissue around the silicone implant.

Breast reconstructions with autogeneous tissue are more complex surgeries that require surgical experience. Autogeneous tissue is usually obtained from abdomen, back, hip and leg. These are:

Abdominal skin and subcutaneous adipose tissue in lower part of abdomen and one of the anterior abdominal wall muscles (transverse abdominis muscle (TRAM)) are transferred to breast region in the form of pedicled or free flap (free tissue transfer—microsurgery) and breast reconstruction is performed. Tummy tuck surgery is also performed in this surgery.

The muscle at lateral part of the back (latissimus dorsi muscle) and the skin that covers this muscle are transferred in the form of pedicled or free flap (free tissue transfer – microsurgery) and used for breast reconstruction. In this technique, the incision scar is usually concealed by bra.

Breast can also be reconstructed by transferring skin and subcutaneous adipose tissue of hip and leg free tissue transfer or microsurgery technique – to breast region.

In breast reconstruction with free tissue transfer technique, skin and subcutaneous fat tissue, also including feeder arteries, are elevated from abdomen, back or hip region and their viability is ensured by anastomosing feeder arteries of the graft to the arteries of the recipient site. Plastic surgeon should be experienced in microsurgery to perform this surgery. Because thin vessels can be sutured only under microscope.

Autogeneous tissues are pretty similar to breast tissue with regard to content. Based on these characteristics, physical behavior of a breast that is reconstructed using autogeneous tissues will resemble the natural breast better and the sensation is restored better and quicker than breast implant surgeries. Satisfaction with outcome will increase when incision scars fade and the tissues used for the reconstruction soften in the postoperative period.

Autogeneous tissues are identical to the normal breast in terms of the respond to weight loss and gain. As a result, symmetry of both breasts can be maintained in case of sagging secondary to excessive weight gain or loss as well as aging after reconstructive surgery. Moreover, breasts reconstructed with autogeneous tissues do not create a contraindication to radiotherapy or chemotherapy.

Several surgeries may sometimes be required to achieve a breast with natural look. The most complicated one is the first surgery, in which breast tissue is constructed. Second surgery is performed to reconstruct nipple and areola (the darker area surrounding the nipple) under local anesthesia and it is easier than the first one. Nipple is constructed using local tissues. Tattoos can be used to replace areola or cutaneous graft can be obtained from nipple of other breast or groin.

Memenin Tümünün Çıkarılması Gerekli Olduğu Durumlarda Meme Başı Bölgesinin Alınması Gerekiyor Mu?

Acıbadem Maslak ve Bakırköy Hastaneleri Genel Cerrahi Uzmanı Prof. Dr. Cihan Uras, memenin tümünün çıkarılması gerekli olduğu durumlarda meme başı bölgesinin alınmasıyla ilgili açıklama yapıyor.

Symmetry of the repaired breast with other breast is not expected in case of unilateral breast reconstruction. This also applies even if other breast is large or sagging. In this case, certain surgeries can be carried out for other breast to achieve symmetry of breasts. These include breast reduction, breast lift (mastopexy) or breast augmentation.

Postoperative period of breast surgery

Postoperative pain is largely managed by medicines. Hospital stay is dependent on complexity of surgery; it may be necessary to stay at hospital 1 to 2 days, if reconstruction is not performed, or otherwise, hospital stay is 2 to 5 days. Patients are discharged 1 day after operation, if breast-sparing surgery is performed, or patients are discharged in 1 to 2 days. Drains are generally placed to prevent collection of fluid and they are usually removed several days to 1-2 weeks after the surgery depending on the surgery technique.

Although return to daily activities after the surgery varies according to surgery technique in treatment of breast cancer, it usually takes several days to 4 weeks. For autologous reconstruction patients, hospital stay may be longer relative to breast reconstruction with implants.

Patients can take a bath as usual 2 days after the surgery, even if drain is not removed, provided no water should leak into drains. Wound dressing on drains should be changed after each shower. Although contact of surgical wounds with water does not cause any problem as of 2 days after the surgery, it is necessary to avoid severe irritation of the wound.

No food restriction or a special diet is required, starting several hours after the surgery.

Normal senses cannot be restored with reconstruction surgery, but it may recover slightly over time. Scars mostly fade over time. However, scars never disappear, even if fading takes 1 to 2 years. Patients pay less attention to scar formation as long as the quality of repair is high.

Patients receive chemotherapy before or after surgery for treatment of breast cancer and moreover, these two modalities are followed by hormonotherapy. Age of patient, size of tumor and biological/pathological characteristics of tumor play an important role in selection and duration of treatment.

Tüm Meme Kanseri Hastaları Kemoterapi Almalı Mıdır?

Acıbadem Bursa Hospital, Genel Cerrahi Uzmanı Prof. Dr. Abdullah Zorluoğlu, Kanser üzerine soruları yanıtlıyor.

Chemotherapy is mostly started after surgery in breast cancer. Excluding certain special conditions, chemotherapy is usually the first-line treatment for patients with locally advanced breast cancer that is inoperable or advanced stage breast cancer that has already metastasized to other organs.

Considering treatment of breast cancer, patients with estrogen- and/or progesterone-positive tumors, who are undergone surgery and received chemotherapy, are given hormone drugs (hormone therapy) that are structurally similar to these hormones, but suppress them. 

Tamoxifen is among medicines with proven value in hormone therapy that is another arm of the system therapy; it is used in premenopausal patients for 5 years.

Both chemotherapy and hormone therapy affect the whole body and have systemic effects. Targeted treatments, on the other hand, directly focus on the cancerous tissue and aim to destroy the tumor alone and minimize the systemic effects by using drugs that target markers of the tumor.

There are various methods for targeted biological therapies. The primary one is an antibody that is globally acknowledged and administered to suppress c-erbB2 (HER-2 neu) protein in patients with breast cancer characterized by overexpression of this protein. C-erbB2 protein is present in approximately 1/4 of breast cancer patients.

It is intravenously administered indefinitely for patients with metastatic advanced stage disease and at 3-week or one-week intervals for 1 year in postoperative period for patients with early-stage disease.

The most critical side effect of this treatment is cardiac dysfunctions.

If inflammatory breast cancer is present,

Clinical prognosis of locally advanced stage III inflammatory breast cancers can be poor. This group of patients is primarily started on chemotherapy due to very high risk of systemic metastasis and mastectomy and axillary dissection are required, if sufficient response is achieved. Postoperative chest wall radiotherapy is also very crucial for these patients. Moreover, targeted treatments and various hormone therapies can be started depending on characteristics of tumor.

Radiation therapy burns and harms the breast skin.

In treatment of breast cancer, radiotherapy may lead to a temporary redness in skin which is similar to sunburn. Redness fades over time, after the treatment is completed.

Radiotherapy

Radiotherapy is a treatment modality that is used in approximately ¾ of all cancer patients. Given principles of multidisciplinary treatment, radiotherapy can be used alone for curative treatment or in combination with chemotherapy/systemic treatments before or after surgery. It is also used to help alleviation of complaints caused by the disease.

Radiation Therapy, also called Radiotherapy, uses high-energy X-rays, electron bundles and radioactive isotopes to kill cancer cells and destroy tumors.

Radiation treatment damages the genetic materials of cells at the irradiated area and thus, division and proliferation of these cells are hindered. Radiation kills the cancer cells through ionization. Some cells die immediately, as they are directly affected by the radiation.

Chromosome and DNA of others are damaged and therefore, they lose reproductive capability and finally, they die. Although radiation treatment causes damage in healthy cells along with cancer cells, healthy tissues may recover and gain normal functions again.

A successful treatment is characterized by ability to deliver the appropriate and efficient radiation dose to the tumor, while the dose exposed by surrounding healthy tissues is minimized. There are various methods to achieve these goals. The most common method is external radiotherapy which focuses radiation beams directly to the tumor.

Another method is brachytherapy. Intra-cavitary radiotherapy, which is one of brachytherapy methods, places an applicator which contains radiation seeds into an organ such as uterus, lung bronchus and esophagus. This method is generally used in combination with external radiation.

External radiotherapy is generally the most commonly preferred technique in breast cancer. However, brachytherapy methods can also be used in special circumstances depending on the physician’s preference.

Patients who present with diagnosis or suspicion of cancer are primarily examined and undergo oncologic evaluation to determine a treatment protocol and next, radiotherapy is planned. All radiation treatments are programmed by expert physicians who are educated on this modality (radiation oncologists). Radiation oncologist cooperates with a team of medical physicist and radiotherapy technicians at the application phase of radiotherapy.

Meme Kanserinin Tedavisinde Ameliyat Sırasında Hangi Hastalara Radyoterapi Uygulanır?

Acıbadem Maslak ve Bakırköy Hastaneleri Genel Cerrahi Uzmanı Prof. Dr. Cihan Uras, meme kanserinin tedavisinde, ameliyat sırasında yapılan radyoterapi uygulamasıyla ilgili bilgi veriyor.

In treatment of breast cancer, radiotherapy generally plays a role after surgery and the technique is selected according to the surgical method. If the patient is undergone "breast-sparing surgery", radiotherapy is generally prescribed for almost all patients as a part of treatment in order to minimize risk of recurrence in breast tissue.

Now, single-dose radiotherapy in surgery is an acknowledged approach in patients who undergo breast-conserving surgery depending on technological means and age of patient as well as size and characteristics of tumor. If “mastectomy” is performed, chest wall radiotherapy can be considered, after diameter of tumor, other patient and tumor factors as well as involvement of lymph nodes are evaluated.

Radiotherapy can also be applied to lymph nodes depending on invasion of disease and location of tumor, if axillary lymph nodes are involved.

Preoperative radiotherapy may be rarely considered after chemotherapy for patients with regional or locally advanced cancer.

Radiotherapy plays an important palliative role to alleviate and eliminate complaints, if bone, brain and soft tissue metastases are detected in patients with advanced stage cancer.

Radiotherapy is delivered once a day for 5 days a week, from Monday to Friday. Irradiation takes 3 to 4 minutes, although it may vary according to treatment plan and target zone. However, entire process is completed within 20-30 minutes, including patient’s placement on the treatment table, preparations and adjustment of treatment volume. Total duration of the treatment is decided by Radiation Oncologist. It is necessary for patients to continue the treatment regularly, excluding emergencies.

Breast radiotherapy may sometimes cause redness and peeling in skin, tiredness, fatigue or nausea. These side effects gradually regress and disappear over time, after the radiotherapy is completed. Patients are allowed to take shower with warm water during the radiotherapy, but rubbing or use of bath puff with soap may irritate the target volume and make patient prone to skin reactions.

Hardness in breast tissue and pain are expected in the long-term secondary to surgery and radiotherapy, but these conditions mostly disappear within 6 months to 1 year, but they may persist longer in some cases. The dark discoloration of breast skin fades over time. In very rare cases, radiotherapy may lead to small red spots on breast skin due to rupture of capillaries. However, it is not an issue nowadays.

There are other side effects which may occur in the long term due to radiotherapy volumes or targets. These are generally caused by patient-specific factors. Patients are informed in detail by physicians regarding risk of side effects depending on the irradiated body part and what should be done in treatment.

Technologies Used For Radiotherapy

In radiotherapy, treatment devices, called ‘linear accelerator’, have been used for approximately 50 years. Main mechanism of these devices is as follows. Electrons are accelerated and beams with different energy levels are directed to the tumor depending on needs of patients. Common features of these beams are high-energy, rapid penetration into body and ability to irradiate the whole body.

Recently, developments in computer technology are utilized in radiotherapy. Images acquired by computerized tomography scanner demonstrate the tumors in body. Radiation oncologists mark tumors and healthy tissues on cross-sectional images and next, radiation physicists plan treatment over these three-dimensional images.

In treatment, beams reach the tumor from various angles and a certain safety margin is left around the diseased region. Treatment aims to deliver maximal dose to the diseased body part for converting tumor into a harmless form. Another important goal is to spare the healthy tissue or organs from radiation. Radiation can be harmful for healthy tissues. If normal tissues are irradiated, side effects are more likely.

Recently, 3-dimensional conformal treatment and IMRT have been developed to conserve healthy tissues at maximum level and reduce adverse effects while irradiating the tumor at highest dose. With these methods, intensity of the radiation in target volume is adjusted and dose distribution is almost optimized. While tumor is irradiated at high doses, healthy tissues are conserved to the maximum extent. For example, these methods allow delivery of intended dose to the diseased breast, while lungs, heart, great arteries of heart and other breast are protected in breast radiotherapy..

It allows imaging the target volume before each radiotherapy session. Thus, treatment volume is located and position of the patient is corrected, if there is any deviation. Another advantage of this method is ability to acquire cross-sectional images during treatment. Thus, errors arising out of movement of organs at the periphery of treatment target and the tumor can be detected and corrected during treatment. Accordingly, tumor is irradiated, while damage to healthy tissues is minimized.

Single-dose radiotherapy delivered by linear accelerator implies use of radiotherapy at single dose during surgery.

Image Guided Radiotherapy (IGRT) with IMRT feature and portal kV imaging system, One Variant Trilogy, One Varian DHX RapidArc Linear Accelerator and Treatment Planning System

Varian Varisource HDR Brachytherapy that allows brachytherapy by placing a radioactive substance into body cavities or tissue.

In single-dose radiotherapy, radiotherapy is completed during a surgical procedure. After breast tumor is removed, the special applicator of the device is placed into the location of tumor. Following necessary measurements, high-dose radiation is delivered only to the target zone and therefore, healthy tissues are completely protected.

Conventional Radiotherapy

For patients with breast cancer, radiotherapy is applied using special devices that generate photon and electron, called “linear accelerator”, in specially shielded rooms at Radiation Oncology Departments. Almost all patients who are diagnosed with breast cancer and undergone “breast conserving surgery”, which implies removal of only tumor in breast, need postoperative radiotherapy.

Radiotherapy is preferably started after chemotherapy, if patient will be started on chemotherapy, or it is preferable started at least 3 weeks after surgery for patients who do not require extra systemic therapy or will receive only hormone therapy. For breast radiotherapy patients, computerized tomography is scanned at 2-5 mm intervals to plan the treatment.

Next, a plan is made to ensure delivery of necessary dose to the risky zones of breast, while healthy organs (heart, great arteries of heart, lungs, other breast that are metastasis-free) are conserved. After the plan is approved, patient is placed on radiotherapy that will last 5 to 7 weeks, depending on patient’s condition and discretion of radiation oncologist. For special cases, hypofractionated or short-term therapy is applied. This treatment lasts 2 weeks. Patient receives radiotherapy every day, excluding weekend.

As is the case with conventional radiotherapy, linear accelerator is used for single-dose radiotherapy. In this method, a portable linear accelerator that generates only electron energy is safely used in operating theater; this accelerator does not require as much radioactive protection equipment as conventional linear accelerators for healthcare personnel.

Surgery is carried out jointly by surgical team, radiation oncologist and medical physicist. It is advantageous for patients, as it is not necessary to wait for postoperative wound healing and patients do not need to visit hospital every day for planning and treatment. Thus, radiotherapy is completed during surgery.

After breast tumor is removed, the special applicator of the device is placed into the location of tumor. Following necessary measurements, high-dose radiation is delivered only to the target zone and therefore, healthy tissues are completely protected. Recently, Single-dose radiotherapy or irradiating the location of tumor rather than entire breast with different methods is globally acknowledged, but single-dose radiotherapy is not choice for all patients. Radiation oncologist of the patient, surgeon and pathologist should jointly decide whether this method is appropriate for the patient. Age of patient and pathological characteristics of tumor play important role in this decision.

Single-dose radiotherapy can be given in the form of extra dose therapy. Especially young patients (who meet certain criteria according to pathology report) may need local irradiation of tumor following whole breast radiotherapy after breast-conserving surgery. Treatment lasts approximately 6.5 weeks in these patients. After extra or single dose is delivered during operation, whole breast is irradiated and thus, total duration of treatment is shortened.

However, breast-conserving surgery may not be an option for some patients. If it is necessary to remove entire breast, nipple and areola can be spared to gain better cosmetic outcomes. This is called nipple- and areola-sparing surgery. Risk of recurrence in nipple and retroareolar tissue (that is located beneath the nipple) is minimized through single-dose radiotherapy for this part of breast.

After breast tumor is removed, the special applicator of the device is placed into the location of tumor for single-dose radiotherapy. However, healthy tissues are not damaged.

No. The procedure is very similar to X-ray or computerized tomography experiences.

May I Move?

No. Movement will cause deviation in target volume. However, you can breathe and swallow. You are recommended to breathe with usual rhythm or to avoid deep breathing. Your doctor will inform you about breath holding technique before the radiotherapy.

Will I Be Alone in Room During Treatment?

Yes. However, you will be continuously monitored on audiovisual screen. You can communicate with us, if you have any problem.

Will I Emit Radioactivity Throughout Treatment?

No. Radioactivity delivered for your treatment does not accumulate in your body and therefore, you do not harm loved ones and children.

May I Take Bath?

You can take shower with lukewarm water. However, wash your treatment site with baby shampoo using soft movements, but avoid rubbing. Tap dry your skin with towel and do not use hair drier. Do not rub your skin with bath glove and dry your skin gently. You may use moisturizing soap or cream that is recommended by your doctor for treatment site.

May I Take Sunbath or Swim?

It is necessary to avoid exposure to sunlight during treatment and until the skin heals. We do not recommend swimming in sea or chlorinated water during treatment. Your doctor will instruct you the correct time to swim according to your dermal findings at the end of the treatment.

How Should I Eat?

You may consult to your doctor regarding aspects of your diet that require attention according to the irradiated body part. Try to eat small servings at frequent intervals throughout your treatment. You should necessarily avoid smoking and we do not recommend regular consumption of alcohol. Your doctor will inform you about difficulty swallowing that may develop depending on the target volume of radiotherapy.

Will There Be Changes In My Skin During Treatment?

Redness, similar to sunburn, may sometimes develop on skin of the target volume. Skin may dry and redness may aggravate several weeks later. Sensitive skin may appear darker than pre-treatment skin tone at target volume of radiotherapy. However, these skin tone changes may disappear several weeks after the treatment.

In case of redness, rashes, acne, exfoliation and pus or blisters, self-medication should be avoided and it is necessary to visit a doctor or a nurse. Clothes that fit very tight to the treatment area should not be worn; the sensitive skin of treatment area should not be rubbed, brushed and scratched.

Will My Hair Fall Out?

If irradiated area covers head, scalp hair may fall out along with beard and other facial hair. Since breast radiotherapy does not target the scalp, your hair will not fall out, but armpit hair may be lost in case of axillary radiotherapy.

Can I Maintain My Sex Life?

Excluding patients who receive pelvic radiotherapy (lower abdomen and reproductive organs); other patients may resume routine sex life.

May Radiotherapy Be Repeated?

It is not recommended to repeat radiotherapy for same breast. However, a physician should decide for special circumstances.

Women who receive radiotherapy should avoid physical contact with friends and family members, as they emit radioactivity.

X-Rays used for treatment of breast cancer do not accumulate in the body. There is no reason to avoid physical contact with people, except acting carefully to avoid a potential damage to the treatment site.

What is Lymphedema, How is It Treated?

As a result of breast cancer treatment, lymphedema may develop in arms depending on number of axillary lymph nodes dissected along with the breast.

Lymphedema is faced by one out of every four patients following treatment of breast cancer.

Initial symptoms of lymphedema manifest on proximal parts of hands and feet. Pain worsens in arms and legs. Skin of these body parts becomes tense and rough. Sensory deficit and joint stiffness may be seen in hands and feet. Strain and tenderness may develop in elbow or behind the knee.

Please click for more details on types of lymphedemas and treatment options.

Life After Breast Cancer

Diagnosis and treatment of breast cancer may cause psychological wearing and major depression in women. If psychological support is available, women may more quickly return to daily life. Diet, exercise and strict compliance to follow-up visits require attention against risk of recurrence.

Psychological Counseling in Breast Cancer

Given the fact that even being diagnosed with a simple disease impairs our daily life routines, diagnosis of breast cancer will, undoubtedly, have catastrophic psychological, social and economic effects. Being diagnosed with breast cancer for a woman means facing risk of losing economic power, job and a part of the body that creates the sexual identity as well as dysfunction of this body part or even her life.

In this regard, diagnosis of breast cancer paves the way for negative thoughts and fear in both patients and family members. On the other hand, medical technologies allow treatment of cancer and many patients regain former healthy status after treatment.

Negative thoughts arising out of diagnosis of breast cancer and ambiguity of treatment devastate existing adaptation mechanisms and cause the mechanisms to be underutilized. Future expectations and plans may be disrupted after diagnosis of breast cancer and these patients feel like they have lost power over own life. This may result in feelings such as fear, anxiety and helplessness.

You Are Diagnosed with Breast Cancer, What Will Happen?

The major fear of women with breast cancer is about metastasis or recurrence of cancer, suffering from pain and death.

Women with breast cancer go through certain psychological stages after being diagnosed and throughout the treatment. You may also proceed to these stages. Usually, the first reaction to diagnosis is “denial.” You may not believe you have been diagnosed with breast cancer, since it is truly difficult to accept you have breast cancer. Many people initially go into shock and deny diagnosis. Denial may be replaced with anger. You may find yourself constantly asking “Why me?”

You may feel angry with people around you and express fury against them. You may try to rationalize the cause and you may think “I have breast cancer, as my family distressed me too much”. Next, you may proceed to other stage that is defined as “bargaining” by experts. You may start running internal bargains and you may have certain thoughts such as “I will beat breast cancer, as I quit smoking” or “It was me who caused this disease and it is also me who will defeat it”.

Bargaining is usually followed by “depression” and “grief.” You cannot deny you have the condition after a short while once treatment is started. Surgery and treatment may start to limit your daily life. You may feel hopeless and desperate. Once this stage is done, “acceptance” starts.

You will feel neither sad nor angry at this stage. Acceptance does not mean abandoning all hopes. You will be strongly holding on to your treatment at this stage. However, it is necessary to mention that not all patients with breast cancer go through all these stages. Also, not all patients experience these stages identically.

What are Psychological Effects of Treatment Process?

All these challenging consequences of being diagnosed with cancer will be psychologically wearing and sometimes, a psychological disorder may occur. Research reports that the risk of accompanying psychological disorder is 50 percent in breast cancer. Psychological disorders that develop most commonly in breast cancer are depression and anxiety disorders.

When Should You Seek Psychological Counseling?

• If you are constantly feeling upset, anxious, sad, nervous or uneasy,
• If you believe you are unable to solve your problems,
• If you hesitate to share your problems with your physicians, family or social circle,
• If you experience difficulty in focusing your attention,
• If you cannot control your temper

We recommend you to seek counseling from a psychologist or a psychiatrist. Severing ties with life due to thoughts on your illness may affect your treatment. You should avoid taking such steps. Receiving psychological support, when required, will keep the aforementioned mood at bay.

If your finances do not allow this type of counseling, you should ask your physician all and every questions you may have, share feeling of restlessness with your physicians and all family members and loves ones and you also try to find your way out by cooperating with your physician. Sharing your problems will also alleviate your psychological stress.

What Are Benefits of Psychological Counseling?

• Increases quality of life by alleviating fear and anxiety,
• Makes you cope with your disease better and easier,
• Facilitates adaptation to your new life,
• Helps you cope with problems in various aspects of your life due to treatment and the disease,
• Guides you to see positive aspects of your life.
• Affects your physical health positively by boosting your immune system,
• Prevents risk of a more severe psychological disorder in the future, if you are at risk.

Does Your Psychology Affect Breast Cancer?

Our body is constantly communicating with our mind. Having a better mood affects our body positively. For example, if we get a headache when we are sad, we feel the ache more severely when compared to when we are happy. Thinking positively has positive effects on our immune system. However, this statement should not be misinterpreted: “I should never feel bad and I should never have negative thoughts”.

Everyone goes through bad mood with or without a cause. Nobody can constantly be very happy, anxiety-free, cheerful or energetic; therefore, you should not worry about negatively affecting your health when having bad thoughts. Minor mood swings do not affect your overall health.

Do You Have To Maintain Positive Attitude Constantly?

Thinking positively and being constantly happy do not imply believing that everything will be nice; rather, it means facing realities of your disease, understanding your options and continuing to cope with your disease. Here, it is important to minimize periods of time you feel bad and strictly focus on your disease. Try to focus on other activities, notice your negative feelings and accept and express them to help manage such periods.

You can try to maintain most part of your life as usual and even to add new elements to your life, if possible. This approach ranges from visiting a new place to new hobbies or meeting new people. Remember that new activities boost the immune system.

What Can You Gain Through Breast Cancer?

Breast cancer does not only bring negativity. You will be a stronger person while fighting this disease, even if you do not recognize it. You will have a better insight about yourself, discover ways to reach your goals, recognize your strengths, overcome your limitations, experience living the moment as well as learn to cherish every moment of life and focus on beauty in your life. You will even see your quality of life has increased and your life has been enriched, once your treatment is completed.

Loss of Breast Damages Body Image!

Breast cancer is a disease that is perceived to threaten being a woman. Removal of breast may put heavier psychological burden on women with breast cancer. Loss of breast is deemed far different from losing any other part of the body.

Loss of breast is equalized to loss of femininity, fertility, sexual attraction and sexuality. Therefore, removal of breast devastates the body image in women, self-confidence decreases and some women may experience problems with sexuality. This effect is more potent in younger women than older ones.

Suggestions to Boost Your Psychology Throughout Treatment

• Try to maintain your routine daily life as much as possible unless instructed otherwise by your physician or as long as your physical condition allows. You can prevent disruption of your social life due to your disease (work, school, etc.).
• Sharing your feelings on your disease and treatment process will help you accept your disease and will provide relief.
• You should not shy away from seeking psychological counseling, when you need it.
• Going out and being active will have positive effect.
• Occupying yourself mentally, even if not physically, will keep you from constantly focusing on your disease.
• Exercising will make you relax in physical and psychological terms and feel empowered, but intensity of exercise should be instructed by your doctor.
• Relaxation exercises and yoga will have positive effects on your psychology and body.
• Following a healthy diet will make positive contributions to your treatment.
• Communicating with other cancer patients and sharing your respective experiences with each other will help you feel better.

Diet After Breast Cancer

Eating very carefully and maintaining optimal body weight are among most important measures that should be taken to prevent breast cancer.

Correlation between breast cancer and diet is as important as it is in other cancers. Studies demonstrate that diet is effective in treatment of cancer by 30 to 40 percent. According to Data from American Institute of Cancer Research, maintenance of optimal body weight is among most important issues to prevent breast cancer. Physical activity, minimum alcohol consumption and lactation are other points…

Women with optimal body weight are known to have less risk of breast cancer in menopausal period when compared to overweight women. Moreover, weight gain increases risk of recurrence in individuals who are diagnosed with breast cancer. Sex hormones, insulin and insulin growth factor 1 in blood of obese people increase waist circumference. All these factors pose a risk regarding breast cancer.

Decrease Fat Intake

Risk of breast cancer can be reduced by limiting energy intake and maintaining ideal body fat ratio. Risk of breast cancer increases in people who consume excessive fat in post-menopausal period, as the body burns less fat. Risk is known to be lower when 20 to 25 percent of total energy intake comes from fats. The figure can increase to 30 percent in risk-free people. Diet rich in Omega-3 fat is also known to decrease risk of cancer.

Limit Alcohol Consumption

There is a correlation between alcohol consumption and breast cancer. Adequate or excessive intake of folic acid from foods, such as dark leafy vegetables (for example, spinach), liver, heart, melon, orange juice, artichoke, beet, broccoli, gombo and dry legumes is known to decrease risk of breast cancer in postmenopausal women. Alcohol consumption is known to decrease concentration of folic acid in blood and thus, risk of cancer increases. Alcohol consumption is recommended to be limited to 1 glass per day, if necessary, since drinking 3 or more glasses of alcohol per day increases risk of breast cancer.

Breastfeed

Breastfeeding decreases risk of cancer in both mother and baby. Unless there is a specific problem with development of your infant or your physician suggests otherwise, feeding only with breast milk is recommended for the first 6 months.

Which Foods Should Be Prioritized?

Green tea: The polyphenol in green tea provides protection against breast cancer. Several studies show that breast cancer is less common in people who regularly drink green tea compared to those who do not. It reduces volume of tumor cells by helping the body burn fats.

Fish: The Omega-3 fatty acid and EPA lowers cancer risk. Experts recommended eating medium-sized fish once or twice a week.

Crucifers (radish, white radish, and Russian turnip), broccoli, and Brussels sprout: They contain isothiocyanate that reduces risk of breast cancer by affect the metabolism of estrogen especially in premenopausal women. Other effective ingredients are carotenoid, isoflovan and Vitamins A, C and E that reduce the risk.

Carrot, zucchini, and cauliflower: They contain lignan that reduces risk of cancer through anti-estrogenic effect especially in postmenopausal women. They are recommended to be consumed together with foods that contain Vitamin C. Whole grain foods, sesame seed, garlic, extra virgin olive oil, apricot, peach, pear, grape, winter squash and cherry are other vegetables and fruits that are rich in lignan.

Milk and dairy: Milk, cheese, yoghurt and dairy are rich in calcium. It is known that risk of breast cancer increases in women with low calcium intake. Considering consumption of milk and dairy, it is necessary to avoid the whole ones. Low-fat or skimmed milk and dairy help both weight control and protection against cancer. Experts recommend products that contain Vitamin D in calcium intake.

There is no food that prevents development or sudden-onset of breast cancer. Although it is known that certain foods increase risk, there are studies that report contrary findings. It is widely acknowledged that consumption of vegetables decrease risk of cancer by 25 percent.

Avoid fat-rich foods after treatment. Make larger rooms for green tea, fish, crucifers, milk and dairy, carrot, broccoli, zucchini and cauliflower in your diet.

It is necessary to avoid certain foods that trigger development of cancer through negative interactions with tissues. These foods that you should remove from your table are whole-fat foods, fried meals, smoked and salted meats as well as barbecued meat.

Wrong

It is not necessary to make decision of treatment quickly and lay the burden on family members by including them in decision-making process.

Correct

Breast cancer affects the entire family. Each member of family has feelings, fears and anger that should be taken into consideration regarding this disease. The best approach is to discuss all treatment options and their effects clearly. Joint decisions may strengthen family bonds and facilitate post-treatment adaptation for everyone.

Exercise After Breast Cancer

Exercise is an essential factor for all periods of life. However, people who are operated on for breast cancer especially need exercising. These exercises aim to help the patient return to normal activities as soon as possible.

What Does Exercise Aim?

• Restoration of the erect posture.
• Eliminate stiffness in neck, low back, chest and shoulders
• Restore range-of-motion, strength and flexibility in stiff body parts
• Increase lung capacity after operation or anesthesia
• Boost cardiovascular well-being and heart-lung capacity
• Regulate blood pressure by elevating level of endorphin
• Eliminate depression, weakness and tiredness
• Prevent lymphedema by facilitating drainage of lymph fluid
• Prevent scar formation
• Avoid from frozen shoulder
• Most importantly, boost fighting spirit of patient

What Should Be Gradually Done For Exercise After Operation?

Rehabilitation should be started as soon as possible to strengthen weak muscle groups that have lost flexibility after surgery and to help flexibility and strength of affected joints. Rehabilitation focuses on muscles of shoulders, neck, chest, back and rotator cuff in the initial phase, while abdomen, low back and legs are prioritized in subsequent stages.

Posture muscles are trained again to correct posture disorders and ensure more appropriate body posture. Involved muscles are trained again to restore safer mobility of patients. Deep breathing is trained by rehabilitating muscles of chest, rib cage and back and thus, diaphragm and lungs gain more room for movement. Efforts are made to increase physical and general condition in order to accelerate postoperative convalescence and to tolerate chemotherapy and radiotherapy better.

Another important target of these exercises is to reduce weight gain during and after chemotherapy, radiotherapy or menopause, increase strength and boost or maintain fitness, body composition and bone density. Thus, individual can recognize own power and feel well.

Physical condition and healing periods are not same for everybody. Therefore, patients are evaluated in all phases of the program in order to create personalized plans. Exercises are always started with easy moves with minimal repeats. Next, they are gradually increased. Too quick advancement may result in injury and sickness. It is necessary to contact the physician who planned the program, if even minor problem is faced.

What Should Be Taken Into Consideration In Rehabilitation?

It is necessary to mobilize as earlier as possible after surgery. However, sudden and quick moves should be avoided.

• Arm should be elevated and supported with 2 pillows while lying or sitting in order to prevent swelling of arm after the surgery.
• Stretching exercise should be done several times a day for both halves of the trunk and each move should be repeated for 3 to 5 times.
• If pain and tiredness persist, it is wise to rest.
• Walking at short distances for several minutes twice of thrice a day may even restore strength after surgery.
• Lifting objects heavier than 1 to 1.5 kg should be avoided in early postoperative period especially by the affected arm.
• One should act carefully in order not to carry any object heavier than 2.5 kg in the long term in order to prevent swelling in arm.
• Shoulder bags should not be used, because shoulders straps may cause lymphedema by exerting pressure on shoulder.
• One should be sure that postoperative swelling regressed and surgical wounds completely healed before starting active exercise.
• One should focus on native rhythm of body and track own insight.
• In case of suspicion, one should consult to primary doctor, nurse or physiotherapist.
• It is necessary to make efforts every day even for a minor improvement. Being self-assertive is very crucial for improvement.

• Pushing moves and activities over the head should be avoided in the early period.
• Abdominal and lumbar exercises can be started 10 weeks after surgery. Spine should be stabilized by placing a thin support beneath the hip during these exercises and excessive load should not be born on the spine.
• Exercises should be done slowly and smoothly to avoid tiredness and dizziness, f the blood count is low.
• Safest ones are condition exercises that include walking and cycling in this period.
• Quality of the exercise is more important that the quantity. When it is done right, it provides more benefit even in lower numbers.

Generally, long-term programs that are modified for each stage are recommended for patients who are undergone breast surgery. Program is planned in accordance with physical characteristics, duration of healing, type and complexity of surgery, co-existing systemic problems, and additional treatments such as chemotherapy and radiotherapy.

Disease-specific exercises are combined with those which strengthen muscles of abdomen and legs and stabilize the spine. These are followed by aerobic and strengthening exercises that aim to boost endurance, speed the metabolism, increase muscle fitness and bone density and to improve body composition.

Pain, numbness, stiffness, restricted movement, strength loss and swelling are most common musculoskeletal problems that are faced after breast cancer surgery.

Physical condition and recovery periods are different for every patient. Therefore, these exercise programs are personalized for each patient.

What are Stages of Exercise Program?

• It is wise to start with extending and flexing the elbow, rotating the wrists and opening and closing fists. Swelling regresses, if these moves are repeated several times throughout the day.
• They are continued in sets of 2 after they are performed easily and safely. One should rest after each set.
• Exercise session should not be prolonged in early postoperative period; it is wise to repeat moves several times in the day time.
• Upper extremity exercises should be performed in maximum 3 sets with 10 repeats.
• Program should always include mild warm up before the exercise and mild stretching after the exercise.
• Arms should be elevated above level of heart using pillows at night.
• It is necessary to walk short distances every day.

• Deep breathing exercises have a great role in this period as they alleviate pain and ensure relaxation along with relief of spasm in muscles of back and chest.
• Walking slowly at frequent intervals increases endurance and prevents muscle atrophy.
• Warm up before exercise and stretching movements afterwards are necessary.
• Duration of walk can be prolonged in this period.
• Resistance band exercises can be started, after surgical wounds heal.

• It is rationale to start more active walks.
• Stationary bicycle and swimming are recommended to be started 6 weeks after surgery for arm and shoulder health.
• Frog style swimming is recommended in the early period. Free style and backstroke swimming should be avoided for 2 months after the surgery.
• Butterfly style should also be avoided, if lymph node is dissected or an implant is placed.
• Pilate’s ball, resistance bands and small weights can be used in this period.
• These exercises are decided in accordance with patient’s overall health and past experience of exercise.

Follow-up After Breast Cancer

Patients should be followed up through detailed health assessments in first 3 years after treatment of breast cancer.

Breast cancer relapses locally – at the surgical site- by 30 percent and in distant organs by 70 percent. Recurrence generally occurs within the first 3 years. Therefore, it is necessary to follow up patients very closely especially in the first three years. Follow-up visits are generally scheduled as follows: At 3-month intervals in the first three years, semi-annually in subsequent two years and annually beyond five years.

Which Examinations Are Ordered?

Whole body bone scan, chest (PA) X-ray, liver ultrasound and various tumor markers as well as alkaline phosphatase are analyzed at certain intervals in patients with breast cancer and results are recorded for future comparisons. Tomography of Thorax and Abdomen, plan roentgenograms in case of bone ache and MRI may be ordered along with general body scan, such as PET-CT, if required.

What should be taken into account?

Complaints of patients are assessed and detailed evaluations are made in follow-up visits. Examinations are considered unnecessary for patients with no complaint or suspicious finding. However, detailed examinations are planned for patients with any suspicious finding to investigate the underlying cause. First mammography is scanned 4 to 6 months after radiotherapy in patients who are undergone breast-conserving surgery and it is repeated annually. Annual radiologic examinations are necessary for those who underwent mastectomy.

Given the risk of relapse of breast cancer, patients should be followed up after treatment. Follow-up visits should be scheduled at quarter intervals in the first three years, semiannually in subsequent two years and annually beyond five years.

Women with past history of breast cancer should have bone scan, CT, blood tests and X-ray every year.

These additional tests might be required in some cases. Routine physical examination and mammography at annual intervals is recommended for women who are healthy without relapse for at least 5 years. In case of radiotherapy, chest X-ray can be ordered every year.