Some of the symptoms include:

• A lump or abnormality in the shape or feel of the breast
• A lump in the underarm area
• A generalized swelling of all or a part of the breast
• An irritation or dimpling of the skin on the breast
• Nipple retraction (nipple turning inward)
• Rash, redness or scaliness on the nipple or breast skin
• Spontaneous discharge from the nipple

Please consult your doctor if you are unsure about a symptom.

Despite the prevailing opinion that young women don't get breast cancer, the reality is that they can and do. In fact, one in every 229 women between the ages of 30 and 40 will be diagnosed with breast cancer in the next 10 years. Following are some other startling facts about breast cancer in young women:

• Breast cancer is the leading cause of cancer death in women ages 15 to 44.
• Approximately 11,100 women age 40 and under will be diagnosed with breast cancer this year.
• There are more than 250,000 women diagnosed with breast cancer at age 40 or under currently living in the United States.

YSC does not endorse the practice of a formal BSE, which you can read more about in our YSC BCYW_Research&Trials_Position_Papers Position Paper on Breast Self Examination (BSE) and Early Detection. Instead, until there are reliable early detection and high-risk screening methods, YSC recommends young women be familiar with their breasts and be able to detect any change from the norm. We recognize that performing self exams might be the best way for some women to become familiar with their breasts, and therefore we do not discourage women from doing so. However, it is important that young women know the facts about breast cancer and the limitations of current early detection methods.

There are essentially four types of biopsies:

• Fine Needle Aspiration - Conducted right in your doctor's office, a long thin needle is inserted into the mass, to draw out representative cells. If the lump cannot be felt (e.g., only showed up on a mammogram), then a sonogram can be used simultaneously to ensure the needle is inserted into the suspicious group of cells. One risk of inaccuracy here is that the report can come back benign if the mass contained both cancerous and non-cancerous cells, but the needle only withdrew the non-cancerous cells.

• Core Biopsy - Conducted in the radiologist's office, a core biopsy uses a slightly larger needle (about the size of the lead in a pencil) to take a plug of tissue for a broader sampling of cells. Like the fine needle aspiration, a core biopsy may be done in conjunction with a sonogram.
• ABBI Biopsy - The Advanced Breast Biopsy Imaging system is similar to the machine used for core biopsies, but removes a greater amount of tissue, including healthy tissue. Conducted under local anesthesia, the ABBI also leaves a scar from an incision on the breast.

Breast pain is most commonly associated with the menstrual cycle and therefore is referred to as cyclical pain. It is thought to be related to hormone activity in combination with a reaction from the breast tissue. Studies show that most women are more concerned about the possibility of cancer than the pain itself. There are treatments available to help with this pain. Some physicians may recommend limiting consumption of caffeine or reducing salt intake. If necessary, doctors can offer medicinal interventions.

Non-cyclical breast pain is much less common and can be caused by a trauma such as an injury or a breast biopsy. In both cases, if you are experiencing breast pain it is important to take the time to find a breast specialist to examine your breasts and determine what steps should be taken, if any.

Cysts – These are fluid or tissue filled sacs occurring most commonly in women approaching menopause. These are often observed by doctors over time or drained using fine needle aspiration. There are several types of cysts as described below:

• Fibroadenomas – These are smooth, round and hard lumps that can usually move easily around the breast. This lump can be anywhere from 5mm to 5cm and may become larger during pregnancy or nursing. Fibroadenomas will usually disappear or get smaller over time and therefore are normally left alone, especially in younger women in which they are most common. However, the procedure for removal is simple and some women may choose to have the lumps removed.
• Fat Necrosis – This is an often painless swelling of fatty breast tissue, often occurring after surgery or injury to the breast. This tumor can look like cancer and is therefore sometimes removed by surgical biopsy.
• Sclerosing Adenosis – Is an enlargement of breast lobules which is sometimes painful and can contain calcifications.

• What type of lump do I have?
• Will I need to have a fine needle aspiration?
• Will I need to have a biopsy?
• What are the risks and benefits of removing the lump?
• What are the risks and benefits of "watching and waiting"?
• Does my condition increase my risk for breast cancer?
• What are my treatment options?
• Would changing my diet help my condition?

Stop, react, adjust, and make a game plan. Allow yourself moments alone to give yourself time to process your thoughts and be in touch with your feelings – get away to places that make you feel calm, relaxed and good about yourself. Don't necessarily do anything yet. Moments alone will allow you to get your head clear enough to understand what it is you want to do next, determine with whom you need to share your news, in what order, how and when. Begin to make lists of all the questions you want to ask your doctor and all the people who can possibly help you or might know something about your diagnosis.

It is normal to have trouble dealing with your diagnosis and treatment. Many women find talking face-to-face with a group of other women who are living with breast cancer helps. Support groups are not for everyone, so you need to try different things to determine what is helpful to you. Some young women find that going to a support group where everyone is significantly older is isolating. Some areas have support groups specifically for young women, but many do not. Fortunately, there are other options to reach other young women living with breast cancer besides local support groups. You may meet them online on a bulletin board, such as the ones in the YSC Community. Discussion rooms allow you to find other young women to e-mail or speak with on the phone. Ask your hospital social worker if he or she knows of groups in your area or other young women who wish to talk with others. Visit <link to Get_Involved_Affiliates>YSC’s Affiliate</link> page to find out if there is a YSC support group near you.

The following is a list of the many doctors you may encounter during your breast cancer experience:

• Surgeon (breast or general): Depending on the size of the community in which you live and the availability of breast surgery specialists, you might choose a breast surgeon or a general surgeon who has performed a number of breast surgeries. He or she will be your lead doctor through what is frequently the initial phase of cancer treatment. However, in some cases, if he or she determines from the biopsy or mammogram that the tumor is large, your surgeon might ask you to consult an oncologist to determine if chemotherapy is warranted to shrink the tumor prior to surgically removing it (called neoadjuvant chemotherapy).
• Plastic Surgeon: If you choose to undergo reconstructive surgery, you should choose a plastic surgeon who will work with your breast surgeon. Not only will they be sharing the operating room if your reconstruction process is begun during the mastectomy surgery, but they will need to agree on which type of reconstructive surgery is most appropriate for your body type and desired outcomes.
• Pathologist: Although it's not up to you which pathologist your surgeon chooses to work with, the pathologist is still a critical member of your team. He or she will perform several tests on pieces of the tumor removed to determine the aggressiveness of the cancer and the extent to which it has or has not spread through your body. This pathology report will be the basis for what your oncologist recommends.
• Medical Oncologist: A medical oncologist is an expert in the use of a variety of modalities used to treat cancer, including chemical and hormonal therapies. This is the doctor who will determine and oversee your chemotherapy regimen, if it's required. While your surgeon will have oncologists to whom they can refer you, you are completely free to choose your oncologist. When the surgery phase is complete, your surgeon will essentially hand you over to your oncologist, who will become your lead doctor.
• Oncology Nurses: The nurses who administer your chemotherapy treatments will be some of the most valuable sources of information in terms of practical tips to help you cope with your cancer treatment. If there is a nurse that you particularly like and find helpful, don’t hesitate to request him or her for subsequent treatments.
• Radiation Oncologist: A radiation oncologist is the doctor who plans a program of radiation therapy (i.e., local treatment of breast cancer with high dose x-rays), using physics to determine how to effectively radiate the entire breast for maximum impact on any remaining cancer cells, while minimizing damage to the healthy tissue. Although your medical oncologist can refer you to a radiation oncologist, there will be others to choose from, especially if you are at a large medical center. Ask around. The nurses, receptionists - even other patients in the waiting room - all may be able to give you information about the reputations and personal styles of the radiation oncologists.
• Radiation Therapist: Radiation therapists are the technologists who run the machines that administer your daily radiation treatment. There might be a few different people operating the machine you are assigned to, and although you do not choose them, like nurses, they will quickly become your friends because you will be seeing them daily for several weeks.
• Psychologist or Psychiatrist: Depending on your emotional state at various stages of your recovery, you might want to take advantage of the mental health resources the hospital can provide. Do not be afraid or ashamed to ask your surgeon or oncologist for recommendations if you feel yourself falling apart, feeling depressed, overwhelmed by fear or anxiety, or having difficulty coping. Remember, your doctors should be looking at you as an entire individual to be treated. Therapists affiliated with the hospital should be particularly adept at handling cancer and survivorship issues. If you need help, get it.
• Social Worker: Believe it or not, there are a wide variety of social and economic aspects to breast cancer that you may have never imagined. Since you may be overwhelmed right now simply adjusting to your diagnosis and physical changes, you might rely on a social worker to identify extra sources of support for you. They can help you find support groups, secure community assistance and even help in managing the insurance and financial aspects.
• Nutritionist: Good nutrition is important during treatment and throughout survivorship. Eating well can help you feel better and stay stronger and is good for your overall health. Ask your doctors if there is a nutritionist on staff who can review your diet: 1) while you are undergoing treatment, as there are certain foods that might help you tolerate chemotherapy and its side effects better than others; and 2) following treatment, when you will want a healthy diet forever.
• Geneticist: If you come from a family with a high incidence of breast cancer, you might want to consider genetic testing to help make your treatment decisions. If you are a carrier of the BRCA1 or BRCA2 gene mutationand are at high risk for recurrence, development of cancer in the other breast or ovarian cancer, you may want to consider more aggressive surgeries. Some women elect to have a mastectomy, or even a bilateral mastectomy, (removal of both breasts), as a preventative measure. However, think very carefully about genetic testing, as there are a host of ethical, legal and insurance implications should such information become part of your publicly available medical history. Ask yourself if there is anything you would do differently than what you are doing today if you discovered you carried the gene mutation. If there isn't, don?t bother to see the geneticist.  YSC encourages young women to speak with a genetic counselor about the host of medical and psychological implications of genetic testing.
• Gynecologist: Your gynecologist should be informed and have copies of all your medical reports. If your hormones have been affected temporarily by chemotherapy (e.g., you experience menopausal symptoms such as hot flashes or irregular or absent menstrual periods), your gynecologist will be helpful to speak with about managing your reproductive cycle. Also, once you've had breast cancer, he or she might want to monitor you more carefully for other types of reproductive cancers.

Choose an NCI designated Comprehensive Cancer Center or a large teaching/university hospital. Ask everyone you know – doctors, family, friends, co-workers – even if you think they've never known anyone with breast cancer. Talk to other survivors and call breast cancer organizations to get referrals. You will hear certain names over and over. Those are the doctors you want to consult. Remember that treatment for breast cancer is a process and you will have many decisions to make along the way, so you need to find a doctor whose judgment you trust. Positive attributes to look for in a doctor can be:

• compassion and empathy
• honesty and straightforwardness - someone who is informative but not patronizing
• consideration of your needs as a whole human being, not just the cancer tumor
• knowledge of the latest advances in breast cancer treatments
• openness to second opinions on care and your feelings about treatment options
• accessibility (someone who could be paged or called 24 hours a day)

• What type of breast cancer do I have?
• What stage is my breast cancer?
• Should I get a second opinion from another pathologist? Why or why not?
• What was the grade of the tumor (rate of cell growth)?
• What lab tests were done on my tumor?
• What were the results?
• Are these the most accurate tests available?
• What other tests are available?
• Was my tumor estrogen-receptor positive? What does that mean?
• Was my tumor progesterone-receptor positive? What does that mean?
• Was my tumor HER2/neu positive? What does that mean?
• Are there other tests that I should have (e.g., bone scan, CT scan)?
• Can you recommend good sources of information (books, websites) for me to read to better understand my breast cancer?

You and your surgeon will decide upon a lumpectomy (also referred to as breast conservation) or a mastectomy, based upon many factors such as:

• Type of breast cancer. For the two most prevalent types -- infiltrating ductal or infiltrating (or "invasive") lobular carcinoma -- a lumpectomy may suffice, since these types are usually contained within one portion of the breast in a clearly delineated tumor. However, if the cancer is spread throughout the breast tissue, a mastectomy may be necessary.
• Absolute size of tumor. The larger the tumor, the more likely a mastectomy will be required and will likely offer a better cosmetic result.
• Location of tumor(s). If the tumor is located in a place that would diminish a lumpectomy's cosmetic results (e.g., around or beneath the nipple), a mastectomy might be the preferred alternative.
• Size of tumor relative to breast size. If you are small-breasted with a fairly large tumor, a mastectomy with reconstruction will likely provide the better cosmetic result. If you are large-breasted, removal of the tumor by lumpectomy might not even be noticeable.
• Other health issues. Since a lumpectomy is almost always followed by radiation treatments, you may not be a candidate for lumpectomy if you are unable to have radiation for a variety of other, unrelated health reasons. For example, if you have certain collagen vascular diseases or skin disorders, you may or may not be a candidate for either radiation or reconstructive surgery, due to potential complications.

Taking into account all these factors, your surgeon will propose the best course of treatment for you. Sometimes he or she might offer you a choice, and sometimes the recommendation might be strongly directed to one or the other alternative. You must make the final decision yourself. Some women opt for a mastectomy even though their doctors say that lumpectomy will suffice, because it provides them with more emotional comfort.

There are several different types of mastectomies.

• Total or Simple Mastectomy - The removal of the entire breast (including the nipple), but no lymph nodes under the arm.
• Modified Radical Mastectomy - The removal of the entire breast (including the nipple), the lining over the chest muscles, and many of the lymph nodes under the arm.
• Radical Mastectomy - The removal of the entire breast (including the nipple), the lining over the chest muscles, the chest muscles, and all the lymph nodes under the arms.
• Skin-sparing mastectomy - This type of surgery involves the removal of the same amount of breast tissue but a much smaller incision allowing for minimal scarring and salvaging a large portion of the skin. With this type of procedure reconstruction is done in the same surgery. As this is a new treatment and the long term effects are yet to be seen it is important to discuss with your doctor the risks and benefits.
• Subcutaneous Mastectomy - Surgery which leaves the nipple and overlaying skin intact making reconstruction easier but also increasing the risk that cancer cells will remain. Usually only used for prophylactic mastectomies.

To see pre- and post-reconstruction images please visit: Susan Love MD or order: Show Me Photo Collection of Breast Cancer Survivors': Lumpectomies, Mastectomies, Breast Reconstructions and Thoughts on Body Image, Third Edition.

Technically referred to as an axillary node dissection or sentinel node dissection, the removal of one, some, or all of the lymph nodes under your arm on the side of the affected breast provides significant information to the oncologist in determining what type of treatment may be required beyond surgery. Breast cancer cells can travel and spread through the lymph nodes or the bloodstream. Since the lymph nodes from the chest area are connected through the underarm area before dispersing out to the body, the surgeon can remove a sampling from that area to determine if any cancer cells have spread beyond the chest. If no cancer cells are identified in the lymph nodes, the doctors may conclude that the cancer was locally contained, meaning it had not spread beyond the breast. Alternatively, if there are cancer cells in the nodes, doctors may want to treat the cancer more aggressively to kill those cells that have traveled beyond the chest and prevent the further spread of carcinogenic cells to other organs and promote cancer growth in other areas of the body.

In some cases, a radioactive dye will be injected into the tumor site during surgery. After a few minutes, the surgeon can track how the dye reaches through the lymph nodes. The first, or sentinel, node that the dye reaches is then the only one removed. The theory is that if cancer cells are migrating to the body from the breast, they would also travel to this node first. While the patient is still under anesthesia, a pathologist analyzes the sentinel node. If it is free of cancer, the surgeon might remove one or two more nodes surrounding that sentinel node just to be sure, but can conclude with 95% accuracy that the others are negative. The woman then keeps most of her lymph nodes intact and is spared the lymphedema and cellulitis risks of axillary node dissection.

If, however, the sentinel node contains cancer cells, the surgeon will continue with an axillary node dissection to determine the extent of the cancer spread.

While there are no known ways to prevent lymphedema, the best defense against complications is to be extra careful about preventing injury, trauma, infection or cuts on the hand and skin of the arm. Here's how:

• Keep your arm and hand clean and moisturized.
• Avoid cuts or punctures of the skin; for example, avoid cutting cuticles, drawing blood or receiving intravenous medications in the affected arm.
• Avoid excessive pressure on the arm, such as tight fitting clothes or jewelry, blood pressure monitors, heavy handbags or shoulder straps.
• Wear gloves or protective handgear for any activity where the affected hand might be exposed or vulnerable (e.g., gardening, dishwashing, cooking, housecleaning, sewing, sports).
• Avoid sunburn and tan gradually. Wear sunscreen with at least SPF-15.
• Avoid burns of any kind.
• Avoid insect bites. Carry insect repellent with you throughout the summer.
• Avoid extreme heat, cold or sudden temperature changes.
• Avoid salty foods. Salt retains fluid.
• Avoid lifting more than 10 pounds, either by carrying heavy items or lifting weights at the gym.
• Avoid activities with constant repetition. Give your arm an occasional rest if you can't avoid repetition.

Lymphedema, a chronic swelling of the hand and/or arm, is caused by blockage in the lymph system to the arm. Lymphedema is unlikely following sentinel node dissection but more common after axillary node dissection. The blockage is usually due to scar tissue from surgery or the less effective drainage in the absence of the lymph nodes you had removed. It can also be caused by radiation to the area where your lymph nodes were removed. In addition to swelling, lymph system damage can result in limited mobility and vulnerability to infection or cellulitis. Pay attention to early warning signs. Call your doctor at the first signs of pain, discomfort or swelling. Don't leave these symptoms untreated - especially if you suspect an infection, which could quickly become serious.

If you are undergoing a lumpectomy, you'll be sent home from the hospital within 24 hours. Once you are taken into surgery, the actual procedure takes 2-3 hours, including the lymph node dissection. After a few hours in the recovery room, upon your awakening and stabilization of vital signs, you'll be moved to your room. The next day you will be walking around and will most likely be sent home.

The surgery associated with a mastectomy requires a longer hospital stay, generally 3-4 days. The surgery itself may last up to 6-7 hours if your plastic surgeon teams with your general surgeon to begin the reconstruction process.

• What kind of surgery do you recommend for me and why?
• How much of my breast will be removed?
• Will I be able to have breast reconstruction?
• What are the advantages and disadvantages of having reconstruction at the time of my initial surgery?
• Will lymph nodes need to be removed?
• Am I a candidate for a sentinel lymph node biopsy?
• How many times have you performed this procedure?
• Am I a candidate for chemotherapy before my surgery (called 'neo-adjuvant chemotherapy')?
• What do I need to do to prepare for my surgery?
• Should I meet with a plastic surgeon before the surgery to discuss reconstruction?
• Will I have a local or general anesthetic?
• Where will the scars be and what will they look like?
• What side effects should I report to you?
• Will I need to stay overnight in the hospital?
• What kind of follow-up care will I need?
• How long will I need to plan to miss work or limit other daily activities?

• Can I have a copy of my pathology report and an explanation of what all the items on my report mean?
• Did you get clear margins during the surgery?
• How many lymph nodes were removed?
• How many (if any) contain cancer cells?
• Were there any cancer cells found anywhere outside my tumor?
• What are our next steps?

• Local skin reactions – These can include itching, redness or dryness and scaling of the skin. The degree of skin reaction is varies widely among individuals. Skin irritation can continue for up to two weeks following the end of treatment.  Ask your doctor how you should treat any skin reactions.
• Fatigue – The onset of fatigue is correlated with your exposure to radiation. That is, the more radiation therapy you need the more fatigue you may experience. These feelings of fatigue should disappear following treatment.

• Why do I need radiation?
• What type of radiation will be employed?
• How long will each treatment take?
• When should I start treatment?
• Who will be giving me my treatments?
• Do I need to bring someone with me to my treatments?
• What are the possible side effects?
• How long will they last?
• Are there any treatments for these side effects?
• What are the risks?
• Is there anything that I can do now or during treatment to minimize the side effects and risks?
• Can I continue normal activities during treatment?
• Will the cost be covered by my insurance?
• What kind of follow-up and monitoring will I need after my radiation treatments are done?

Chemotherapy is the therapeutic use of a variety of chemicals - given intravenously or orally - to systemically destroy any carcinogenic cells that might be lingering anywhere in your body. The administered chemical agents travel through the bloodstream and reach most cells in the body. The chemical agents can target carcinogenic cells and interfere with their replication and growth thus preventing the spread of cancer. The administered chemical dose has been exacted from years of research studies to determine the maximum tolerable amount of chemicals (which do not cause permanent damage to healthy tissues) resulting in the greatest probability of killing any remaining cancer cells. Administering a series of treatments of the same or different drugs over time ensures that chemotherapy will remove all carcinogenic cells as they undergo different phases of their growth cycle.

Chemotherapy may be given in the following settings:

• Adjuvant - This is the most common form of treatment, delivered after surgery to treat microscopic carcinogenic cells which are not visibly detected, but which may cause the cancer to recur or spread.
• Neo-adjuvant - This is treatment administered before surgery, to reduce the size of the tumor in the hopes of requiring a less invasive surgery and increasing the chances for "clear margins" or total removal of cancerous tissue.
• Metastatic - This treatment is administered to decrease the size of tumors and slow the spread of the disease. In the hopes of stabilizing the progression, this treatment is used to reduce the symptoms of the disease, as well as to improve the quality of life for the patient.

Depending on what combination of drugs your oncologist recommends, the kind of cancer you have and how you respond your treatment sessions will be given on and off daily, weekly or even monthly. The time periods between these treatments allow your body to recover from any damage to healthy cells, such as white blood cells in the bone marrow. The drugs will be administered to you either by intravenous drip, which can take anywhere from thirty minutes to a few hours, or orally in pill form. Chemotherapy can be administered on an outpatient basis at a hospital, in a special treatment clinic or even in your doctor's offices.

Everyone experiences chemotherapy differently. Some people find they have days when they feel fine, and days that they're not so fine, days when they are more energetic or much weaker than usual, days with a hearty appetite and days they don't even want to smell food. There are days when white blood cell counts are low, which makes one more susceptible to infections. There are treatments available to help prevent and/or reduce the nausea and vomiting brought on by chemotherapy as well as treatments to strengthen the immune system. You should speak with your doctor about the best ways to manage the side effects of your treatment.

The most common side effects of the most common chemotherapy drugs are as follows:

• Adriamycin (doxorubicin): More common side effects are hair loss, nausea and diarrhea. Bone marrow suppression is also a risk. Less common but more worrisome is a problem with the regulation of a specific heart valve. While the risk is dosage dependent, for the standard treatment regimen today, it is actually less than 1%. Anyone receiving this drug will go for cardiac testing (MUGA scan) and be monitored appropriately for the duration. The drug may also cause the urine to be a reddish color.
• Cytoxan (cyclophosphamide): More common effects include metallic mouth taste while drug is being administered, and later nausea, appetite changes (anorexia), hair loss, low blood counts, abdominal pain, skin rashes and diarrhea. Irregularities in your menstrual cycle can also occur, and as total dosages increase, fertility declines, and the likelihood of premature menopause increases. Rarely, there can be toxicity to the bladder (to prevent this, drink plenty of fluids) and metabolic abnormalities.
• Methotrexate: More common affects include nausea, mouth sores, low blood counts, hair loss, headaches and drowsiness. In some cases it can cause itching, skin rashes and dizziness. In rare cases, it can cause severe toxicity of the liver and bone marrow which requires regular monitoring with blood testing.
• 5-Fluorouracil: Fairly well tolerated. More common effects are nausea, appetite changes, diarrhea and low blood counts. Rarely, skin darkening or pigment changes can occur.
• Taxol (paclitaxel): The primary concern is about an allergic reaction, so everyone receiving this drug gets pretreatment with antihistamines and anti-inflammatory drugs. Make sure that someone is in the room with you for at least the first hour of your first Taxol treatment in case you do have an allergic reaction. Common side effects are hair loss, nausea, low blood counts, joint pain and less frequently, neurological side effects such as weakness, numbness and tingling (which may be temporary during treatment or more permanent, depending on dosage and duration).
• Taxotere (docetaxel): There is also a concern for severe allergic reaction. Swelling in the legs and fluid build-up, sometimes in the lungs, can be a problem. More common effects are excessive tearing, fatigue, loss of appetite and severe nausea.

Other more general side effects of chemotherapy may include temporary memory loss (often called "chemo brain"), fatigue and depression, all induced by a complex interaction of chemical, physical and emotional factors.

• Why do I need chemotherapy?
• What type of chemotherapy do you recommend? Why?
• What are the benefits and risks of this type of chemotherapy?
• Will chemotherapy affect my fertility?
• Are there some kinds of chemotherapy that are more likely to cause premature menopause?
• Are there ways to prevent fertility loss during treatment?
• How long after will I be able to get pregnant?
• How will my doses be chosen and will I be getting a full dose for my exact height and weight?
• How will I know if the chemotherapy is working?
• Are there clinical trials that I should consider?
• What are the short-term side effects?
• Are there any long-term side effects?

Hormone therapy is beneficial only to breast cancer patients who have hormone (ER+ or PR+) receptor positive cancer. This will be indicated on a pathology report. Receiving hormone therapy is not dependent upon age or stage of cancer although the type of hormonal agent may be.

Tamoxifen is the most commonly prescribed hormonal treatment. It is prescribed for newly diagnosed women, patients with metastatic disease and sometimes, for women at high risk for contracting breast cancer. The usual dosage is 20 mg per day for five years taken in pill form once or twice daily. Tamoxifen blocks the effects of estrogen on breast tissue without changing your body's production of estrogen.

Ovarian suppression and ablation refer to the cessation (stopping) of the production of natural hormones by the ovaries to block those hormones (estrogen and progesterone) from reaching cancer cells and causing them to grow.

• Ovarian suppression: A pharmaceutically induced menopause. Women will experience a gradual change, which is close to the effects of natural menopause. The long term risks and benefits of ovarian suppression drugs, taken in combination with drugs like tamoxifen and chemotherapy, are currently being researched. There are currently three trials (SOFT, PERCHE, and TEXT), which you can get information about by visiting the BCYW_Research&Trials Research and Clinical Trials section of our website.
• Ovarian ablation: Achieved through the surgical removal of the ovaries (oophorectomy). Young women who experience ovarian ablation experience menopause immediately and permanently, and the side effects are likely to be more severe than the effects of natural menopause.

• Am I a candidate for hormonal therapy?
• Will I benefit from hormonal therapy?
• How much will I benefit?
• For what hormonal therapies do I qualify?
• Which will work best for me and why?
• Will hormone treatments affect my bone density?
• What are the side effects of this treatment?
• Will these treatments affect my ability to get pregnant?
• What is the likelihood that I will go into early menopause?
• As a younger woman, do the current statistics apply to me?
• Are there any clinical trials in which I can take part?
• How long will I be taking this treatment?
• When should I start?
• Will the costs be covered by my insurance?

First, you will need to decide when or if you want to have breast reconstruction. You may want an immediate reconstruction, or you may want to wait to decide which type of reconstruction is right for you, or you may not want to have reconstruction at all.

There are no right answers - only what's right for you. If you will be considering breast reconstruction at any point, you should see a plastic surgeon before your initial surgery. You should also bear in mind that breast reconstruction almost always involves more than one surgery, including nipple reconstruction if you choose it, and possibly surgery on the other breast to make the body symmetrical. Talk to your doctors about the best and worst possible outcomes for your reconstruction. You can have immediate reconstruction in which you wake up from your breast surgery with a newly constructed breast, or you can decide to wait months or even years.

After surgery you will be given a temporary prosthesis that you can wear during your recovery. When you are ready, you can be fitted by a professional for a prosthesis that will fit into pockets sewn into your bra (and swimsuits) to hold it in place. Breast prostheses come in a wide range of shapes, sizes and skin tones. The costs are generally covered by insurance. They are made of silicone to reproduce the natural curves, weight and feel of your breast, including nipple outline.

Get a feel for the different types of reconstructive surgery by asking questions and doing research. There are more surgical options than ever before. It may help to speak with women who have made different choices, including those who have opted to have no reconstruction. 

Immediate Reconstruction – This is done immediately following your breast surgery so that you wake up with a new breast. The reconstruction is done by a plastic surgeon during the mastectomy operation itself. The surgeon and the plastic surgeon work together as a team rather than sequentially. Talk to your surgeon before surgery to see if you are a candidate for the procedure.

Implants – Breast implants are silicone sacs filled with either saline or silicone that are placed behind your chest muscle. Sterile saline (salt water) filled implants are used by physicians much more often than silicone-gel filled implants because of concern that silicone leakage could debilitate the immune system. Usually, the plastic surgeon will implant a tissue expander first. This is like an implant, but it is not fully inflated, and so at first, is smaller than your implant will be. In the weeks following surgery, your plastic surgeon will inject saline into the tissue expander until it is fully expanded. Then you will undergo surgery to remove the tissue expander and replace it with your permanent implant.

Flap Reconstruction – Flap reconstruction depends upon your body type and anatomy. Here, tissue and muscle from another part of your body (tummy, back, thigh, buttocks) is used to make a new breast. There are a number of different techniques available:

• Transverse Rectus Abdominis Myocutaneous (TRAM) Flap – TRAM reconstruction is the most common reconstruction available, taking tissue from the abdomen in a "tummy tuck" procedure. Women who are very thin and lacking excess abdominal fat are not usually candidates for this type of procedure.
• Latissimus Dorsi Flap – This reconstruction involves the latissimus dorsi muscle (a back muscle located underneath the shoulder) which is turned around to recreate a breast. Normally, an implant will also accompany this procedure in order to create a symmetrical breast. Women with smaller to moderate size breasts are the best candidates for this procedure. While it should not affect upper body strength, it may cause unevenness in the back's appearance.
• Gluteal Flap – In this reconstruction, tissue is taken from the upper and lower parts of the buttocks and used to reconstruct the breast. This procedure is usually used if the TRAM flap is not an option due to scarring or lack of excess tissue. It is a complicated procedure because of the need to reattach many blood vessels.
• Deep Inferior Epigastric Perforator (DIEP) Flap – This surgery is much the same as the TRAM flap except the muscles of the abdomen are preserved in this procedure.
• Superficial Inferior Epigastric Artery (SIEA) Flap – The SIEA Flap and its accompanying veins can be an option for some women whose superficial vessels in the abdominal fatty tissue provide the dominant source of blood flow to this region. This procedure is otherwise the same as the DIEP procedure and represents a second choice for women whose superficial vessels are more dominant than the deep inferior epigastric perforators (DIEPs).  It is not known before surgery whether a woman has an adequately sized SIEA blood vessel. These are looked at by the microsurgeon during surgery, and a determination will be made at that time whether they are suitable to supply a flap. 
• Gluteal Artery Perforator (GAP) Flap – The GAP Flap procedure allows for reconstruction using your own body’s tissue when there is inadequate abdominal fat to restore your breast to its proper size and shape.  For the woman who is thin or athletic, the breast may be reconstructed with tissue borrowed from the gluteal area. Skin and fatty tissue are collected from the buttocks/hip region without sacrificing underlying muscles. As with the DIEP procedure, the tissue is then sculpted into the new breast mound.  There is a donor site scar on the buttocks.
• Transverse Upper Gracilis (TUG) Flap – The TUG Flap is taken from the upper inner-thigh area in a crescent shape.  Only a small amount of the gracilis muscle is taken with the flap to ensure a reliable blood supply.  There is no functional consequence to removing the gracilis muscle, which is the same muscle used to reconstruct facial paralysis or forearm injuries.  This flap is coned to create a projecting breast shape, and an immediate nipple and areola reconstruction are also possible with this flap.

Soreness and tenderness are to be expected within the first two weeks of recovery. There may also be swelling or bruising which could last for many weeks. Most women will require the insertion of a drain, in order to prevent the build up of excess fluid. The entire recovery period could last anywhere from four to six weeks. Flap surgeries generally require longer recovery periods.

• When can I get a prosthesis?
• Will it be covered by my insurance?
• Am I a candidate for reconstructive surgery?
• What are the types of surgery currently available?
• Which are possibilities for me?
• Which would you recommend and why?
• What are the costs of reconstructive surgery, and will my insurance cover them?
• Will my breasts look relatively the same? Will they be symmetrical?
• Will I regain sensation in my breasts? Will they feel the same as before surgery?
• How much experience do you have performing this type of reconstruction?
• Are there studies about women's satisfaction with this type of surgery?
• Am I a candidate for immediate reconstruction? Why or why not?
• What are the possible complications?
• How will this affect my other treatments, i.e. chemotherapy or radiation?
• How many surgeries will I need?
• How long is the surgery, hospital stay and recovery period for my type of reconstruction?
• How will the reconstructed breast respond to aging and/or weight gain/loss?
• What are the latest and most innovative technologies available in reconstruction?
• Do you have materials that I can take home and read before I make a decision?
• Do you have pictures of results from previous surgeries you've done that I could look at?
• How can I talk with other women who have already had this type of reconstruction?

A recurrence is when breast cancer returns after you have completed treatment for your initial diagnosis of breast cancer. This can happen within a relatively short period of time after treatment, many years later or never. There are three types of breast cancer recurrence:

• Local recurrence: This is when the breast cancer tumor cells grow back in the original site (or breast). If a mastectomy has been performed, this may mean that the cells grow back in the chest wall skin or nearby tissue.
• Regional recurrence: This is when the breast cancer has spread outside the breast and axillary (underarm) lymph nodes, such as in the pectoral (chest) muscles, internal mammary lymph nodes under the breast bone and between the ribs, in the supraclavicular nodes (above the collarbone) or in the nodes surrounding the neck.
• Distant recurrence: (or metastasis) This is when the breast cancer has spread through the lymph system or bloodstream to other sites in the body such as the bone, lungs, liver, brain or other organs.

Metastatic breast cancer, often referred to as advanced breast cancer, is when breast cancer spreads beyond its original site to a different site in the body. Metastatic breast cancer, or metastasis, most often occurs in the bones, lungs, liver and brain, but can show up in other areas of the body. A breast cancer metastasis is still considered breast cancer, regardless of where it may spread. For example, breast cancer metastasis that spreads to the liver is not liver cancer.

Anything unusual that lasts more than two weeks or is severe should be checked out. Keep in mind that cancer patients still get arthritis and the flu, so don't panic. Most women whose breast cancer has metastasized do not show symptoms until the disease is extensive. Symptoms of metastatic breast cancer may include:

• Bone pain
• A persistent dry cough that continues for an extended period
• Shortness of breath
• Lack of appetite
• Weight loss
• Neurological pain or weakness, headaches

While these symptoms may be possible signs of metastasis to the bone, lung, liver or other parts of the body, this does not mean that every woman who experiences them has metastatic breast cancer. There can be a variety of other reasons why you might experience the above symptoms, and they may have nothing to do with cancer of any kind. The important thing is that you listen and pay attention to what your body is trying to tell you and that you seek medical help to determine what may be causing your particular symptom or condition.

There are several tests used to detect metastatic disease:

• Bone scans
• Chest x-ray
• CAT scan
• MRI scan
• PET scan
• Blood Tests/Tumor marker tests – Measure markers found in the blood that can be followed over time. Two such markers for breast cancer are CEA and CA 15-3. These markers tend to be elevated in women with metastatic breast cancer. However, because the tests are not very sensitive, they are not usually very useful for patients with early-stage breast cancers.

Since every woman is an individual and each situation is unique to her, the treatment options available may vary. However, treatment of metastatic breast cancer generally involves systemic (whole body) treatment such as chemotherapy and/or hormonal therapy. An overview of the various treatments:

• Chemotherapy: Common chemotherapy drugs include Taxol, Taxotere, Adriamycin, Navelbine and Xeloda
• Hormonal Therapy: Common hormonal treatments include Tamoxifen, Raloxifene, Aromasin, Arimidex and Femara (of those, only Tamoxifen is recommended for pre-menopausal women).
• Herceptin: Available only for patients with HER2-overexpressing tumors. Recent data showed that Tykerb is an option for HER2 overexpressing tumors if Herceptin no longer prevents disease progression or is not an option.
• Radiation: Can be used if the metastasis is localized. For example, if cancer has spread to only one or a few closely grouped spots on the bone, radiation may be an option. For metastasis to the brain, whole or partial brain radiation may be considered.
• Surgery: A recent study in the Journal of Clinical Oncology showed that removing the tumor even when breast cancer has metastasized improves survival.
• Ovarian Suppression or Ablation: shutting down or removing ovaries is an option for estrogen receptor positive breast cancers with antiestrogens or aromatase inhibitors.

• The YSC  Programs_Mets MetsLink program is designed to provide information, resources and support for young women with metastatic breast cancer.  
• The YSC Programs_Survivor SurvivorLink</link> program will match young women with others who have been through a similar situation. Contact ResourceLink at 877.YSC.1011 or resourcelink@youngsurvival.org for a referral to a trained SurvivorLink volunteer.
• You can meet and talk with other young women about metastatic disease on the YSC bulletin board, or read Survivor Stories from women living with metastatic disease on our website.
• The Y-ME National Breast Cancer Organization has a 24-hour hotline you can call for services and support: 1.800.211.2141
• www.advancedbc.org is a website dedicated to information and support for women facing advanced breast cancer.
•  www.bcmets.org has an advanced breast cancer list serve for women of all ages, though many young women are represented on the list.
• www.mbcnetwork.org is a national independent advocacy group of and for people with metastatic breast cancer. Their intent is to give metastatic breast cancer patients a greater voice in the breast cancer community.

• Rapid, unusual increase in breast size
• Redness, rash, blotchiness or other skin color changes on the breast
• Persistent itching of breast or nipple
• Lump or thickening of breast tissue
• Stabbing pain and/or soreness of breast
• Feverish breast
• Swelling of lymph nodes under the arm or above the collar bone
• Dimpling or ridging of breast
• Flattening or retracting of nipple
• Nipple discharge or change in pigmented area around nipple

Although the above symptoms may indicate a benign breast disorder, any change to your breast(s) should be reported to your healthcare professional immediately. In addition, these symptoms may appear quickly and suddenly.

Clinical trials are often available for patients with IBC. You can find information on these on the Inflammatory Breast Cancer Research Foundation website – www.ibcresearch.org. In addition, you can visit the BCYW_Research&Trials Research and Clinical Trials section of our website to get information on how to find breast cancer clinical trials.

Clinical trials are research studies in which patients help doctors find ways to improve health and cancer care. Each study tries to answer scientific questions and to find better ways to prevent, diagnose or treat cancer.

Ask your doctor about clinical trials for which you might qualify. You can find a listing of current trials from the BCYW_Research&Trials Research and Clinical Trials section of our website. You can also contact the NCI Cancer Information Service at 1-800-4-CANCER, or visit the NCI website for listings or visit www.breastcancertrials.org.

Once you are finished with your treatment (surgery, chemotherapy and radiation), you will continue to have regular check ups with your doctors. You will see one of your doctors -- surgeon, oncologist and radiation oncologist -- every 8-10 weeks to receive a physical exam as well as a blood test. These exams will become less frequent as time goes on. You will have an annual mammogram (and possibly sonogram), and you may have annual bone scans and/or chest x-rays. It is important that even beyond five years after diagnosis you continue your relationship with your healthcare team and continue follow-up visits although perhaps less frequently.

Part of the aftermath of the breast cancer experience is very similar to the post-traumatic stress disorder syndrome often experienced by war survivors. You may become paranoid about the cancer returning, and you may feel a little like a hypochondriac. These are part of the survival instincts. Every time you have a pain in your joints or bones, you may be frightened that it's a recurrence, rather than just simply an inflammation or strain. You can manage anxiety by realizing that what you are feeling is normal. Don't ever think an ache or pain is too small to mention to one of your doctors, especially if it lasts more than a few weeks. Many women agree that this fear, although present, will subside with the passage of time.

While you might not want to hear about anything to do with cancer, it is important to help yourself by staying informed. Even after treatment, new research and technologies can affect your long-term health.

Many women find that turning their efforts toward action and advocacy at the end of treatment can be both rewarding and empowering. Some take part in marathons or volunteer at local organizations. Young Survival Coalition is the product of women who were determined to turn their experiences into something positive to help empower other young women. Action as seemingly simple as sharing your story can make a huge impact in other young women's lives as well as in the fight for a cure. You can learn more about opportunities in the Advocacy section of our website or read about  Upcoming Events. You might also wish to volunteer for our SurvivorLink program for other young women affected by breast cancer.

Some women can and do become pregnant after breast cancer, but because not enough studies have been done on this subject women should talk to their doctors if they are considering becoming pregnant. It is important to realize that certain cancer treatments can affect one's ability to bear children, and careful thought and planning is necessary to preserve fertility before and during treatment.

There are some clinical issues to consider when thinking about pregnancy after breast cancer:

• Estrogen receptor status of cancer cells – If cancer cells were estrogen-receptor positive, it may be riskier to get pregnant. With the hormonal surges associated with pregnancy, both estrogen and progesterone, it can be possible for dormant cancer cells to become active.
• Impact of chemotherapy on ovaries – At birth, every woman is born with a full complement of eggs in her ovaries to last a lifetime, expending one each month with her menstrual cycle. However, chemotherapy can damage ovaries in a variety of ways. Even if you didn't experience menopause, chemotherapy may kill some eggs completely, or may have damaged your remaining eggs, so they may be incapable of fertilization or may cause genetic defects. To some extent, a fertility specialist can determine the quality of your eggs and whether you have a chance at a successful pregnancy. Treatment may not put you into menopause immediately, but it could happen earlier in life than without a treatment history.  
• Year of survival – While there is some debate, some oncologists recommend that you wait until you are past your five-year survival mark to consider pregnancy due to the impact it may have on your body. Others recommend waiting only two years.
• Limited fertility options – You might be unable to get pregnant the natural way, for a variety of reasons, some of which may have nothing to do with your cancer history. But as a cancer survivor, your options for fertility treatments may be more restricted, as many fertility programs include significant hormone stimulation.
• Extended Treatment – Some women require additional hormonal therapy after treatment, such as five years of Tamoxifen, which can further delay pregnancy.  Speak with your doctor about the possibility of taking a break from Tamoxifen to have children.

• What are my treatment options for my stage of pregnancy/stage of cancer?
• Is there a risk to my baby because of these treatments?
• Can I delay treatment until after the birth? Why or why not?
• What is the likelihood that my cancer will advance with delayed treatment?
• When can I get pregnant after treatment?
• Am I a candidate for in vitro fertilization?
• Can I breastfeed my baby?
• Can you recommend a genetic counselor?

More and more research is being done every year on the subject of breast cancer and pregnancy with the hope that soon women will have more options open to them. You can find some of the more recent studies in the Published Research section of our website, and we encourage women to keep up to date with all new studies and innovations occurring in this field.

You may also want to visit the following websites for more information:

• NCI Pregnancy and Breast Cancer 
• Fertile Hope

Hereditary Breast Cancer and Genetic Testing (FAQs on this topic created together with FORCE)

The benefits of genetic testing can vary depending on individual circumstances. Knowing your BRCA genetic status can be very empowering. Should you test positive for a known mutation, genetic testing can allow you to choose medical options to lower your risk for cancer or detect the disease at an early stage. It may also qualify you to participate in research studies that are looking for better ways to detect cancer early or to prevent cancer. However, not everyone views the knowledge of cancer risk as a benefit. The limitations of the test are complex. Genetic testing impacts both the individual undergoing testing and other members of the family. Some people may find the information and uncertainty associated with risk overwhelming, especially at first. And since the test itself can only identify the two most common genes involved in hereditary breast cancer, under certain circumstances, a negative test may not rule out hereditary breast cancer in your family. Because not every person who carries a mutation will get cancer, it is very important to remember that genetic testing cannot detect breast cancer nor can it tell you with certainty if you will get breast cancer at some point in your life.

The BRCA1 and BRCA2 gene mutations are linked primarily to breast and ovarian cancer, but BRCA2 mutations also carry a somewhat higher risk for other cancers, including melanoma and prostate cancer in men.