The Health Secret We’re Afraid to Reveal

Each of these women has an illness—lupus, breast cancer, bipolar disorder—she wouldn’t admit to anyone … until now.
“She has cancer,” I told my 14-year-old, who wondered why one of her teachers had not returned to work for the new school year.

“Will she be OK?” she asked.

“Well, no,” I said. “She may not live much longer.” I’d just learned that the teacher had been sick for a year and had kept her condition from everyone but a few colleagues. This sudden and devastating news, which spread quickly through the school’s network of mothers and was followed up in a poignant letter from the school soon thereafter, had hit like an emotional atomic blast. No one knew. No one even suspected.

“I understand she’s sick,” my daughter said, “but why would she want to hide it?”

Why, indeed? Aren’t we the gender that talks more and listens better? We usually happily share information, even private information. Why, then, do some women keep mum when illness enters their lives? Here, secret keepers reveal the very personal reasons they hid an illness or condition—and what inspired them to finally spill the beans. And one woman explains why she’s still not telling.

The “don’t call me sick” secret
Breast cancer, a belligerent and unexpected houseguest, arrives on the doorsteps of more than 175,000 American women’s lives every year. But when the threshold belongs to a woman who has made healthy living the cornerstone of her life, that knock on the door may also bring shame—and secrecy.

“I was a real health nut,” says Katreese Barnes, a musician in New York City. “I was judgmental of people who ate foods that weren’t organic or drank water that wasn’t filtered. I felt they were living their lives out of balance.”

When a routine physical exam in 2000 turned up a problem, Barnes was surprised. “The doctor said, ‘You’ve got to get a mammogram today,’” she remembers. “The radiologist was sad-faced.”

Barnes had ductal breast cancer. “Weeks later, I had a biopsy,” she says. “And then I had to have a lumpectomy.”
At the border crossing from healthy to ill, she was horrified at the irony. “Because I’d been so preachy prior to finding out I had cancer, this, for me, was a walk of shame,” Barnes says. She kept her diagnosis secret from everyone except her parents and brother. And—a mere four days after her lumpectomy—she showed up for the new gig she’d landed just before her diagnosis: pianist for the famed on-set band of Saturday Night Live. “I wanted to function as a well person,” she says. “I wanted to work through it. And I did, even when the pain from the lumpectomy lasted for months.” In fact, at holiday time, a classic SNL arrangement of “Jingle Bell Rock” required Barnes to hammer a chord over and over at a rapid-fire pace. But she never let a soul know how much it hurt, much less why it hurt.

Barnes’s cancer returned a year later. “I thought, I’m going to work. I’m not going to be one of those musicians with a disease who needs fund-raisers. There were times, even during the show, when something would trigger a nerve and make me want to cry. But I hadn’t told anyone I had cancer, so I had to keep shifting the focus.”

She tried several different treatment regimens and had regular mammograms until, finally, her readings were clear. Then Barnes slowly let her bandmates know about her illness. Now the pianist is the musical director at SNL, and she’s not above holding her now-public health struggles over her fellow musicians’ heads. “People show up late to work because they have the sniffles,” Barnes says, laughing, “and I say, ‘Hey, I’ve never been late. And I had cancer.’”

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The “you won’t like me anymore” secret
When Susan Crickman started feeling under the weather in 2001, she watched her husband respond with frustration and impatience. That scared her even more than her extreme fatigue and joint pain. Formerly a divorcée with two young children, Crickman was newly remarried to a prominent lawyer in Fredericksburg,

Virginia, and she wanted everything to be perfect. Being sick for more than a year and eventually being diagnosed with lupus (a painful and fatiguing autoimmune disease that affects as many as 1.8 million women) wasn’t part of the plan.

“Even after the diagnosis, I never even said the word lupus to him,” she remembers. “We were an up-and-coming couple. I’d built the office for his law practice. I was afraid he’d think, I married this beautiful wife. We have this great life. Now she has lupus. I was afraid he’d leave me.”

In fact, Crickman went into a deep depression the day after she was diagnosed. “I hid in my bedroom for a week,” she says. “We had a gun collection that my husband had inherited from his father. And I told him to get all the guns out of the house. I said it was because the kids were getting older. But the real story is that after my diagnosis I was completely suicidal.”

Meanwhile, Crickman also kept her diagnosis from her children, afraid they’d equate a serious medical condition with that of their grandfather who’d recently died. “I didn’t want my kids to be worried all the time,” she says. But they were. Her 10-year-old son “would sneak into the room just to make sure I was breathing,” she says.

Then she and her husband started fighting constantly. “I was tired of him screaming at me about why I wasn’t doing the things I used to do. In 2005, I told him to get out. He went and lived with his mother for three weeks."

Soon after, Crickman told her husband and children she had lupus. And after a close friend died, the couple decided to reconcile. Life wasn’t an instant bed of roses, but everyone has learned to cope—“we’re doing it together,” she says.

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The “it’ll hurt my career” secret
Lupus’s sudden flare-ups can make the simplest tasks herculean and render many women unable to work—and afraid to tell employers for fear they’ll lose crucial health insurance. “A company will find any way to get rid of you,” says Mary Anderson (not her real name), 27, who was diagnosed with lupus a year ago.

Anderson’s job as a manager for a laboratory in Las Vegas doesn’t place many physical stresses on her, but there are days she knows her lupus compromises her job performance. Her position requires traveling, and her meds sometimes make driving difficult, even dangerous. And, on top of bone-weary fatigue, Anderson struggles to focus amid the lupus fog. “It’s quite overcoming,” she says. “I’ve been in the middle of doing something and completely forgotten what I was supposed to do. It doesn’t happen often, but it happens enough that I wonder if I should be on disability.”

For now, Anderson is keeping her job, holding off fears that she’ll suddenly be viewed as unworthy of employment. “People start to feel sorry for you, feel you can’t do this or that,” she says. “Because I’m in the beginning of my career, I don’t want the stigma.”

Although she attends a lupus support group, Anderson guards her secret on the job. “I regret that people can’t understand what I’m going through,” she says. “I feel plowed under. But news travels, and I can’t take the risk of someone who may have power or influence over my career finding out. I have to work. I have to keep my insurance.”

And yet. Ruth Blanc, 33, another lupus patient who’d kept her diagnosis secret, found herself suddenly stepping into the light of disclosure—with profoundly positive results. During a remission, she got a human resources position at a New York City–based nonprofit agency, and her first flare-up created suspicion and concern among her supervisors and co-workers. “They said, ‘What happened to you? When we interviewed you, you were vivacious. Now you sound groggy. Are you stressed out?’” Blanc maintained she was fine. “I should have said, ‘No, I’m not fine,’” she says, “but I thought that would make them look for something and maybe even fire me.”

Blanc weathered a hospitalization for another flare-up, but then her world shifted. A year later a new employee in another department suggested that the company participate in a lupus walk. The reason? She had lupus. “My mouth fell open,” Blanc remembers. “I thought, Maybe I should let her know I have lupus, too.” But she kept quiet until a company luncheon for the walkathon. “At lunch, we were going around the room talking about why we were supporting the walk. When it was my turn, I said, ‘I have lupus.’ The words were flying out of my mouth.” Blanc’s unexpected outing of her deepest secret landed on soft, supportive ground. “Everyone was so understanding, so compassionate,” she remembers.

Newly energized, Blanc networked to get better medical care. She also began reading up on her disease, and in March she participated in Lupus Advocacy Day in Washington, D.C. Blanc credits the arrival of that co-worker as a life-changing moment: “She said to me, ‘Ruth, if you’re hiding it, only you know how much you’ve suffered. You can help someone else by telling your story.’”

The “don’t judge me” secret
Growing up in a small Connecticut town, Elizabeth Wageley was hospitalized multiple times for depression, panic attacks, and self-injury. Finally, at age 14, she received a diagnosis of bipolar disorder. She told one teacher. No one else. “People judge,” she says. “Everyone knows everyone else in my town, and word spreads so fast. I wanted to be a normal girl.”

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When Wageley went off to college, she finally saw her opportunity to open up about her illness. With classmates coming from all over, the provincial scrutiny she’d felt faded. “I decided in advance,” she says. “I told one of my friends.”

At work, Wagely made the same decision. “I told one woman, and she and I ended up having a two-hour conversation about our families, about mental illness. I was blown away that I could talk about this. I feel more comfortable now. I realize that if people judge me about this, then they have a problem.”

Now 18 years old, the college student still treads cautiously. Her longtime boyfriend knows. Her friends know. But when she looks into the future, privacy still figures into her landscape. “It boils down to who I’m dealing with,” she says. “If they’re mean and ignorant, I don’t want to tell them. If they’re a kind, understanding person, it’s probably a go.”

Cindy Chandler, 50, has had trouble finding kind, understanding people with whom she wants share her complex medical history. Plus, like many women, she’d been raised not to burden others with bad news. But it was hard to hide because her chronic Lyme disease affected her in lots of ways, including causing painful, lesion-covered skin.

While working for a moving company near her hometown of Smyrna, Georgia, she was asked to leave the home of a client who felt nervous that Chandler’s skin would somehow affect the materials she was helping to pack. On another job, co-workers speculated that her skin lesions were AIDS. “I knew people were talking about me at the water cooler,” she says, “but I didn’t want to go through the whole story of Lyme disease and what it is and does.”

Eventually, after more than six months of dating, Chandler told the man who is now her fiancé. And her “bad news” didn’t burden him one bit. He rallied in ways she had never expected, offering both emotional to financial support. One day of blood tests, she says, can run as much as $2,400. “He takes care of me,” she says. “He’s solid gold.”
source from www.health.com

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Cancer treatment for women: Possible sexual side effects

Sex might be the last thing on your mind as you start thinking about cancer treatment options and cope with the anxiety that comes with a cancer diagnosis. But as you start to feel more comfortable with yourself during cancer treatment and afterward, you'll want to get back to a "normal" life as much as you can. For many women, this includes resuming sexual intimacy with their partners.

An intimate connection with a partner can make you feel loved and supported as you go through your cancer treatment. But sexual side effects of cancer treatment can make resuming sex more difficult. Find out if you're at risk of sexual side effects after cancer treatment and which treatments can cause these side effects.

Who's at risk of sexual side effects?

Women being treated for breast or gynecologic cancers are most likely to experience side effects that make having sex painful or difficult. But cancers anywhere in the pelvic region can cause these effects. Pelvic cancers include:

* Bladder cancer
* Cervical cancer
* Colon cancer
* Ovarian cancer
* Rectal cancer
* Uterine cancer
* Vaginal cancer

Treatment for each of these cancers carries the risk of causing physical changes to your body. But having cancer also affects your emotions, no matter what type of cancer you have. For instance, you may feel anxious and worn out about your diagnosis, your treatment or your prognosis. These emotions can also affect your attitude toward sex and intimacy with your partner.
What sexual side effects are most common?

The treatment you receive and your type and stage of cancer will determine whether you experience sexual side effects. The most commonly reported side effects among women include:

* Difficulty reaching climax
* Loss of desire for sex
* Pain during penetration
* Reduced size of the vagina
* Vaginal dryness

Not all women will experience these side effects. Your doctor can give you an idea of whether your specific treatment will cause any of these.
How does cancer treatment cause sexual side effects?

Cancer treatments that are more likely to cause sexual side effects include:

Chemotherapy
Many women experience a loss of libido during and after chemotherapy. Often the side effects of the treatment, such as fatigue, nausea, hair loss, and weight loss or gain, can make you feel unattractive. Side effects usually fade soon after treatment ends. But it may take time to rebuild your self-confidence to bring back your desire for sex.

Chemotherapy can cause a sudden loss of estrogen production in your ovaries. This can lead to symptoms of menopause, such as a thinning vagina (vaginal atrophy) and vaginal dryness, both of which can cause pain during penetration. Ask your doctor about what you can expect from your chemotherapy drugs, as some can cause permanent ovary damage. Depending on your cancer type, your doctor may prescribe estrogen replacement therapy — also called hormone therapy for menopause — to reduce the sexual side effects you experience. However, women with breast or ovarian cancer should discuss this carefully with their doctors, as some cancers are hormone sensitive. For these women, hormone replacement therapy should be avoided if possible.

Radiation therapy
Sexual side effects related to radiation therapy are most common in women receiving treatment to their pelvic area. Radiation to the pelvis causes:

* Damage to the ovaries. The amount of damage and whether it's permanent depends on the strength of your radiation treatments. Damaged ovaries don't produce estrogen. This causes symptoms of menopause, such as vaginal dryness or hot flashes. If you've already been through menopause, you likely won't experience such symptoms.
* Changes in the vaginal lining. Radiation therapy can irritate healthy tissue in its path. This can cause the lining of your vagina to become inflamed and tender. Penetration during sex may be uncomfortable during treatment and for a few weeks afterward. As the lining of your vagina heals, it may become thickened and scarred, causing your vagina to tighten and resist stretching during penetration. Your doctor might recommend using a vaginal dilator to prevent scar tissue from forming after radiation.

Talk to your doctor about what you can expect from your specific radiation treatments. Some side effects may be preventable. For instance, surgery to relocate your ovaries to another part of your body might spare them from the damage of radiation and preserve your fertility. Ask your doctor about your options.

Surgery
Whether surgery affects your ability to have sex will depend on your type of cancer, where it's located and its size. Surgical procedures that are likely to cause sexual side effects include:

* Radical hysterectomy. Women with cervical cancer may opt for a radical hysterectomy to remove their uterus and related ligaments, as well as their cervix and part of their vagina. A shortened vagina usually doesn't change your ability to have sex, though it may take some adjustment. Women over 40 may also have their ovaries removed during this procedure. If you're premenopausal when your ovaries are removed, you'll experience menopause.
* Radical cystectomy. In this operation for bladder cancer, the surgeon removes your bladder, uterus, ovaries, fallopian tubes, cervix, the front wall of your vagina and your urethra. Your surgeon reconstructs your vagina, though it may be shorter or narrower than it was before surgery. This can make sex painful. If you haven't been through menopause, removal of your ovaries will cause early menopause.
* Abdominoperineal (AP) resection. AP resection is used if you have colon or rectal cancer. Your surgeon removes your lower colon and rectum. Without the cushion of the rectum, you might experience pain in your vagina during penetration. Some women who have an AP resection also have their ovaries removed. If you're premenopausal, this will cause premature menopause.
* Vulvectomy. You may undergo vulvectomy if you have cancer of the vulva. Your surgeon removes the entire vulva, including the inner and outer lips, as well as the clitoris. These play a major part in sexual arousal in women. Removing the vulva and the clitoris can make the area less sensitive and make it harder for you to reach orgasm.

There isn't a clear link between breast cancer surgery and decreased sexual function, though women who undergo surgery to remove one or both breasts (mastectomy) may lose sensation in the breast region. Women who undergo breast-saving surgery (lumpectomy), rather than mastectomy, are more likely to enjoy breast caressing. You may also be self-conscious of your scars after surgery, which can cause a loss of libido.

Hormone therapy
If you have a hormone-sensitive cancer, you might receive hormone therapy through medications, such as tamoxifen, or through surgery, such as removal of your ovaries (oophorectomy). If your cancer is sensitive to hormones, these hormone-blocking therapies can be effective in shrinking or killing the cancer and can decrease the chance of a cancer recurrence.

Both medications and surgery for hormone therapy cause menopausal signs and symptoms, including vaginal atrophy and dryness. Removing your ovaries causes permanent menopause. Side effects of hormone therapy medications usually wear off after you stop taking them. Keep in mind though, that women taking hormone therapy for cancer usually take these drugs for five years or more.
What can you do to regain your sexual function?

Knowing what sexual side effects to expect before you begin your cancer treatment can help you be more prepared to deal with them as you go through treatment. If you experience sexual side effects, find out as much as you can about what's impeding your sexual function. This will help you feel more in control of the situation and help guide you to treatment options. You may also want to:

* Talk with your health care team. You might be embarrassed to talk about the sexual side effects you're experiencing, but don't be. Though talking about sex can be awkward, you'll never find a solution if you don't let someone know what you're experiencing. Write down your questions if it makes you feel more comfortable. In addition, your doctor may be embarrassed or hesitant to talk about sex. If this is the case, ask to be referred to a specialist or seek support from other members of your health care team, such as nurses and counselors.
* Talk with your partner. Let your partner know what you're experiencing and how he or she can help you cope. For instance, you might find that using a lubricant eases your vaginal dryness or changing positions helps you avoid genital pain during sex. Together you can find solutions to ease you back into a fulfilling sex life.
* Explore other ways of being intimate. Intercourse isn't the only option for closeness with your partner. Consider spending more time together talking, cuddling or caressing. Connecting in other ways might help make you feel more comfortable and less anxious about the sexual side effects you're experiencing.
* Talk with other cancer survivors. Your health care team might be able to steer you to a support group in your town. Otherwise, connect with other cancer survivors online. If you're embarrassed about discussing sex face to face with strangers, the online environment provides you anonymity. Start with the American Cancer Society's Cancer Survivors Network.

It may simply take time for you to regain your sexual function after cancer treatment. While that can be frustrating, remember that if you had a positive and satisfying sex life before cancer, you'll likely resume that after your treatment.
source from www.cnn.com

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Sex education: Start discussions early

It's never too early to start talking to your children about sexual matters. Openness, even with young children, will show that sex is an acceptable topic of conversation. Teach your child that you are available to discuss sexual issues, and establish a comfort level — for both of you — with the topic.

Don't feel like you have to include everything in one big discussion. Instead, talk about questions and behaviors as they occur.

Toddlers explore themselves

Between the ages of 18 months to 3 years, children begin to learn about their own bodies. Teach your child the proper names for sex organs. Otherwise, he or she might get the idea that something is wrong with these parts of the body.

It's normal for a child to explore his or her body and to do what feels good. Self-stimulation is one way a child's natural sexual curiosity is manifested. Boys typically pull at their penis, and girls rub their external genitalia.

The concept of privacy

This may be a good time to teach your child about privacy. Masturbation is a normal, but private, activity. If your child suddenly starts masturbating in the middle of a play group, try to distract him or her. If that fails, take your child aside for a reminder about the importance of privacy.

Sometimes, frequent masturbation can indicate a problem in the child's life. Perhaps he or she is under a lot of stress, or isn't receiving enough attention at home. It can even be a sign of sexual abuse. Teach your child that the parts of the body covered by a bathing suit are private, and that no one should be allowed to touch them without permission.

Curiosity about others

By the age of 3 or 4, children are ready to know that boys and girls have different genitals. To satisfy their normal curiosity about each other's sex organs, children may play "doctor" or matter-of-factly take turns examining each other. This exploration is far removed from adult sexual activity, and it's harmless when only young children are involved. As a family matter, however, you may want to set limits on such exploration, discouraging it if you see it going on.

At this age, many children ask the dreaded question: "Where do babies come from?" Try to give a simple and direct response, such as: "Babies grow in a special place inside the mother." As your child matures, you can add more details.

Segregation of the sexes

Between the ages of 5 and 7, children become more aware of their gender. Boys may tend to associate only with boys, and girls only with girls. In fact, they may even say they hate children of the opposite sex.

At this age, questions about sex will become more complex, as your child tries to understand the connection between sexuality and making babies. He or she may turn to friends for some of these answers.

Because children can pick up faulty information about sex and reproduction, it may be best to ask what your child knows about a particular topic before you start explaining it.

Preteen angst

Children between the ages of 8 and 12 worry a lot about whether they are "normal." Penis size and breast size figure heavily in these worries. Children of the same age mature at wildly different rates. Reassure your child that he or she is well within the normal range of development.

What kids should know before they reach puberty

The American Academy of Pediatrics recommends that before they reach puberty, children should have a basic understanding of:

* The names and functions of male and female sex organs
* What happens during puberty and what the physical changes of puberty mean — movement into young womanhood or young manhood
* The nature and purpose of the menstrual cycle
* What sexual intercourse is and how females become pregnant
* How to prevent pregnancy
* Same-sex relationships
* Masturbation
* Activities that spread sexually transmitted diseases (STDs), in particular AIDS
* Your expectations and values

Be honest, open and matter-of-fact

Talking about sexual matters with your child can make you both feel uncomfortable and embarrassed. Let your child guide the talk with his or her questions. Don't giggle or laugh, even if the question is cute. Try not to appear overly embarrassed or serious.

If you have been open with your child's questions since the beginning, it is more likely that your child will come to you with his or her questions in the future. The best place for your child to learn about relationships, love, commitment and respect is from you.
source from www.cnn.com

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Teen weight loss: Safe steps to a healthy weight

Teenage obesity is a dangerous — and growing — problem. But what can you do about it? Plenty. Turn your concern about your teenager's weight into action.

There's no magic bullet for teen weight loss. The key to success is adopting healthy habits that can last a lifetime.

Start with a heart-to-heart

If your teen is overweight, he or she is probably concerned about the excess weight, too. Aside from lifelong health risks such as high blood pressure and diabetes, the social and emotional fallout of being overweight can be devastating for a teenager. Offer support and gentle understanding — and a willingness to help your teen take control of the problem.

You might say, "I can't change your weight. That's up to you. But I can help you make the right decisions."

Dispute unrealistic images

Weight and body image can be delicate issues — especially for teenage girls. When it comes to teen weight loss, remind your teen that there's no single ideal and no perfect body. The right weight for one person might not be the right weight for another.

Rather than talking about "fat" and "thin," encourage your teen to focus on practicing the behaviors that promote a healthy weight. Your family doctor can help set realistic goals for body mass index and weight based on your teen's age, height and general health.

Resist quick fixes

Help your teen understand that losing weight — and keeping it off — is a lifetime commitment. Fad diets may rob your growing teen of iron, calcium and other essential nutrients. Weight-loss pills and other quick fixes don't address the root of the problem. And the effects are often short-lived. Without a permanent change in habits, any lost weight is likely to return — and then some.

Promote activity

Like adults, teens need about 60 minutes of physical activity a day. But that doesn't mean 60 solid minutes at a stretch. Shorter, repeated bursts of activity during the day can help burn calories, too.

Team sports through school or community programs are great ways to get active. If your teen isn't an athlete or is hesitant to participate in certain sports, that's OK. Encourage him or her to walk, bike or in-line skate to school, or to walk a few laps through the halls before class. Suggest trading one hour of after-school channel surfing for shooting baskets in the driveway, jumping rope or walking the dog. Even household chores such as vacuuming and washing the car have aerobic benefits.

Eat breakfast

If your teen fights the alarm clock the way it is, getting up even earlier to eat breakfast may be a tough sell. But it's important. A nutritious breakfast will jump-start your teen's metabolism and give him or her energy to face the day ahead. Even better, it may keep your teen from eating too much during the rest of the day.

If your teen resists high-fiber cereal or whole-wheat toast, suggest last night's leftovers. Even a piece of string cheese or a small handful of nuts and a piece of fruit can do the job.

Snack wisely

It can be tough to make healthy choices when school halls are lined with vending machines, but it's possible. Encourage your teen to replace even one bag of chips a day with a healthier grab-and-go option from home:

* Frozen grapes
* Oranges, strawberries or other fresh fruit
* Sliced red, orange or yellow peppers
* Cherry tomatoes
* Baby carrots
* Low-fat yogurt or pudding
* Pretzels
* Graham crackers
* String cheese

Watch portion sizes

When it comes to portions, size matters. Encourage your teen to scale back and stop eating when he or she is full. It might take just one slice of pizza or half the pasta on the plate to feel full — and there's no shame in sharing a meal, ordering a smaller portion or taking home leftovers.

Count liquid calories

The average 12-ounce can of soda has 150 calories and 10 teaspoons of sugar. The calories and sugar in fruit juice, specialty coffees and other drinks can add up quickly as well. Drinking water instead of soda and other sugary drinks may spare your teen hundreds of calories and a day's worth of sugar — or even more. For variety, suggest flavored water, seltzer water or unsalted club soda.

Allow occasional treats

Late-night pizza with friends or nachos at the mall don't need to derail your teen's healthy-eating plan. Suggest a breadstick and marinara sauce instead of garlic bread dripping in butter and cheese, or a shared snack rather than a full-size order. Let your teen know that he or she is in control — and an occasional indulgence is OK. A trend toward healthier habits is what really matters.

Make it a family affair

Rather than singling out your teen, adopt healthier habits as a family. After all, eating healthier foods and getting more exercise is good for everybody.

* Encourage the entire family to eat more fruits, veggies and whole grains. Be sure to set a good example yourself.
* Leave junk food at the grocery store. Healthy foods sometimes cost more, but it's an important investment.
* Try new recipes or healthier alternatives to family favorites.
* Banish food from the couch to curb mindless munching.
* Plan active family outings, such as evening walks or weekend visits to a local recreation center.

Be positive

Being overweight doesn't inevitably lead to a lifetime of low self-esteem. But your acceptance is critical. Listen to your teen's concerns. Comment on his or her efforts, skills and accomplishments. Make it clear that your love is unconditional — not dependent on weight loss. Help your teen learn healthy ways to express his or her feelings, such as writing in a journal.

If your teen is struggling with low self-esteem or isn't able to cope with his or her weight in a healthy manner, consider a support group, formal weight-control program or professional counseling. Additional support may give your teen the tools to counter social pressure, cultivate more positive self-esteem and take control of his or her weight. The benefits will last a lifetime.
source from www.cnn.com

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Breast cancer

From MayoClinic.com
Special to CNN.com

Introduction

Breast cancer, the second-leading cause of cancer deaths in American women, is the disease women fear most. Experts predict 178,000 women will develop breast cancer in the United States in 2007. Breast cancer can also occur in men, but it's far less common. For 2007, the predicted number of new breast cancers in men is 2,000.

Yet there's more reason for optimism than ever before. In the last 30 years, doctors have made great strides in early diagnosis and treatment of the disease and in reducing breast cancer deaths. In 1975, a diagnosis of breast cancer usually meant radical mastectomy — removal of the entire breast along with underarm lymph nodes and muscles underneath the breast. Today, radical mastectomy is rarely performed. Instead, there are more and better treatment options, and many women are candidates for breast-sparing operations.

Signs and symptoms

Knowing the signs and symptoms of breast cancer may help save your life. When the disease is discovered early, you have more treatment options and a better chance for a cure.

Most breast lumps aren't cancerous. Yet the most common sign of breast cancer for both men and women is a lump or thickening in the breast. Often, the lump is painless. Other potential signs of breast cancer include:

• A spontaneous clear or bloody discharge from your nipple, often associated with a breast lump
• Retraction or indentation of your nipple
• A change in the size or contours of your breast
• Any flattening or indentation of the skin over your breast
• Redness or pitting of the skin over your breast, like the skin of an orange

A number of conditions other than breast cancer can cause your breasts to change in size or feel. Breast tissue changes naturally during pregnancy and your menstrual cycle. Other possible causes of noncancerous (benign) breast changes include fibrocystic changes, cysts, fibroadenomas, infection or injury.

If you find a lump or other change in your breast — even if a recent mammogram was normal — see your doctor for evaluation. If you haven't yet gone through menopause, you may want to wait through one menstrual cycle before seeing your doctor. If the change hasn't gone away after a month, have it evaluated promptly.

Causes

In breast cancer, some of the cells in your breast begin growing abnormally. These cells divide more rapidly than healthy cells do and may spread (metastasize) through your breast, to your lymph nodes or to other parts of your body. The most common type of breast cancer begins in the milk-producing ducts, but cancer may also begin in the lobules or in other breast tissue.

In most cases, it isn't clear what causes normal breast cells to become cancerous. Doctors do know that only 5 percent to 10 percent of breast cancers are inherited. Families that do have genetic defects in one of two genes, breast cancer gene 1 (BRCA1) or breast cancer gene 2 (BRCA2), have a much greater risk of developing both breast and ovarian cancer. Other inherited mutations — including the ataxia-telangiectasia mutation gene, the cell-cycle checkpoint kinase 2 (CHEK-2) gene and the p53 tumor suppressor gene — also make it more likely that you'll develop breast cancer. If one of these genes is present in your family, you have a 50 percent chance of having the gene.

Yet most genetic mutations related to breast cancer aren't inherited. These acquired mutations may result from radiation exposure — women treated with chest radiation therapy for lymphoma in childhood or during adolescence when breasts are developing have a significantly higher incidence of breast cancer than do women not exposed to radiation. Mutations may also develop as a result of exposure to cancer-causing chemicals, such as the polycyclic aromatic hydrocarbons found in tobacco and charred red meats.

Researchers are now trying to discover whether a relationship exists between a person's genetic makeup and environmental factors that may increase the risk of breast cancer. Breast cancer eventually may prove to have a number of causes.

Risk factors

A risk factor is anything that makes it more likely you'll get a particular disease. Some risk factors, such as your age, sex and family history, can't be changed, whereas others, including weight, smoking and a poor diet, are under your control.

But having one or even several risk factors doesn't necessarily mean you'll develop cancer — most women with breast cancer have no known risk factors other than simply being women. In fact, being female is the single greatest risk factor for breast cancer. Although men can develop the disease, it's far more common in women.

Other factors that may make you more susceptible to breast cancer include:

• Age. Your chances of developing breast cancer increase with age. Close to 80 percent of breast cancers occur in women older than age 50. In your 30s, you have a one in 233 chance of developing breast cancer. By age 85, your chance is one in eight.
• A personal history of breast cancer. If you've had breast cancer in one breast, you have an increased risk of developing cancer in the other breast.
• Family history. If you have a mother, sister or daughter with breast or ovarian cancer or both, or a male relative with breast cancer, you have a greater chance of also developing breast cancer. In general, the more relatives you have who were diagnosed with breast cancer before reaching menopause, the higher your own risk. If you have one first-degree relative — a mother, sister or daughter — who was diagnosed with the disease before age 50, your risk is doubled. If you have two or more relatives, your risk increases even more. Just because you have a family history of breast cancer doesn't mean it's hereditary, though. Most people with a family history of breast cancer (familial breast cancer risk) haven't inherited a defective gene, such as BRCA1 or BRCA2. Rather, cancer becomes so common in women who live into their 80s and beyond that random, noninherited breast tumors may appear in more than one member of a single family.
• Genetic predisposition. Between 5 percent and 10 percent of breast cancers are inherited. Defects in one of several genes, especially BRCA1 or BRCA2, put you at greater risk of developing breast, ovarian and colon cancers. Usually these genes help prevent cancer by making proteins that keep cells from growing abnormally. But if they have a mutation, the genes aren't as effective at protecting you from cancer.
• Radiation exposure. If you received radiation treatments to your chest as a child or young adult, you're more likely to develop breast cancer later in life. Your risk is greatest if you received radiation as an adolescent during breast development.
• Excess weight. The relationship between excess weight and breast cancer is complex. In general, weighing more than is healthy increases your risk, particularly if you gained the weight as an adolescent. But risk is even greater if you put the weight on after menopause. Your risk also is greater if you have more body fat in the upper part of your body.
• Early onset of menstrual cycles. If you got your period at a young age, especially before age 12, you may have a greater likelihood of developing breast cancer. Experts attribute this risk to the early exposure of the breast tissue to estrogen.
• Late menopause. If you enter menopause after age 55, you're more likely to develop breast cancer. Experts attribute this to the prolonged exposure of the breast tissue to estrogen.
• First pregnancy at older age. If your first full-term pregnancy occurs after age 30, or you never become pregnant, you have a greater chance of developing breast cancer. Although it's not entirely clear why, an early first pregnancy may protect breast tissue from developing genetic mutations that result from estrogen exposure.
• Race. White women are more likely to develop breast cancer than black, Hispanic or Asian women are, but black women are more likely to die of the disease because their cancers are found at a more advanced stage. Although some studies show that black women may have more aggressive tumors, it's also likely that the disparity is at least partially due to socioeconomic factors. Women of all races with incomes below the poverty level are more often diagnosed with late-stage breast cancer and more likely to die of the disease than are women with higher incomes. Low-income women often don't receive the routine medical care that would allow breast cancer to be discovered earlier.
• Hormone therapy. Treating menopausal symptoms with the hormone combination of estrogen and progesterone for four or more years increases your risk of breast cancer. In addition, therapy with estrogen and progesterone can make malignant tumors harder to detect on mammograms, leading to cancers that are diagnosed at more advanced stages and that are harder to treat. Using estrogen alone hasn't been shown to increase breast cancer risk in postmenopausal women.
• Birth control pills. Use of birth control pills is associated with an increased risk of breast cancer in premenopausal women. The risk seems to be greater for women who use birth control pills for four or more years before their first full-term pregnancy, but since delayed first pregnancy is also a risk factor, part of the risk could be attributed to that. Overall, risk of breast cancer for users of birth control pills is small and appears to be confined to the short term. Risk levels return to normal within five to 10 years after discontinuing use. Using birth control pills also doesn't appear to further increase breast cancer risk in women with a family history of breast cancer or with a personal history of benign breast disease. Because this is an area of ongoing study, talk with your doctor about the latest information on the pill and breast cancer.
• Smoking. Evidence is mixed on the relationship between smoking and breast cancer risk. Some studies show no link between cigarette smoking and exposure to secondhand smoke and breast cancer. Others suggest that smoking increases breast cancer risk. Exposure to secondhand smoke and breast cancer risk remains an area of active research. Despite the controversy surrounding this issue, there are clear health benefits — other than minimizing breast cancer risk — to quitting smoking and limiting your exposure to secondhand smoke.
• Excessive use of alcohol. According to the American Cancer Society, women who drink more than one alcoholic beverage a day have about a 20 percent greater risk of breast cancer than do women who don't drink. To reduce your breast cancer risk, limit alcohol to no more than one drink daily.
• Precancerous breast changes (atypical hyperplasia, lobular carcinoma in situ). These changes are discovered only after you have a breast biopsy, most commonly done for another reason. If these changes are present, your risk of breast cancer is higher than it is for women who don't have one of these so-called "markers." If you have carcinoma in situ, discuss treatment and monitoring options with your doctor.

• Mammographic breast density. Breasts described as "dense" have a high ratio of connective and glandular tissue to fat. On X-ray images, dense breast tissue looks solid and white, so it can mask tumors and make mammograms difficult to interpret. Increasingly, though, breast density is also being recognized as a breast cancer risk factor in itself. The mechanism behind this increased risk is unknown.

  Your age and menopausal status affect your breast density. Younger women tend to have denser breasts. Hormones also have an effect — higher hormone levels generally mean denser breasts. Still, the actual increase in risk due to mammographic density is very small. If you're at high risk of breast cancer and your mammograms are difficult to interpret because of breast density, your doctor may recommend additional screening tests.

When to seek medical advice

Although most breast changes aren't cancerous, it's important to have them evaluated promptly. See your doctor if you discover a lump or any of the other warning signs of breast cancer, especially if the changes persist after one menstrual cycle or they change the appearance of your breast. If you've been treated for breast cancer, report any new signs or symptoms immediately. Possible warning signs include a new lump in your breast or a bone ache or pain that doesn't go away after three weeks. In addition, talk to your doctor about developing a breast-screening program, which may vary, depending on your family history and other significant risk factors.

Screening and diagnosis

Screening — looking for evidence of disease before signs or symptoms appear — is the key to finding breast cancer in its early, treatable stages. Depending on your age and risk factors, screening may include breast self-examination, examination by your nurse or doctor (clinical breast exam), mammograms (mammography) or other tests.

Breast self-examination
Breast self-examination is an option beginning at age 20. By becoming proficient at breast self-examination and familiar with the usual appearance and feel of your breasts, you may be able to detect early signs of cancer. Learn how your breasts typically look and feel and watch for changes. If you detect a change, promptly bring it to your doctor's attention. Have your doctor review your examination technique if you'd like input or you have questions.

Clinical breast exam
Unless you have a family history of cancer or other factors that place you at high risk, the American Cancer Society recommends having clinical breast exams once every three years until age 40. After that, the American Cancer Society recommends having a yearly clinical exam.

During this exam, your doctor examines your breasts for lumps or other changes. He or she may be able to feel lumps you miss when you examine your own breasts and will also check for enlarged lymph nodes in your armpit (axilla).

Mammogram
A mammogram, which uses a series of X-ray images of your breast tissue, is currently the best imaging technique for detecting tumors before you or your doctor can feel them. For that reason, the American Cancer Society has long recommended screening mammography for all women over 40.

Two types of mammograms include:

• Screening mammograms. Screening mammograms are performed on a regular basis — about once a year — to check your breast tissue for any changes since your last mammogram.
• Diagnostic mammograms. Your doctor may recommend a diagnostic mammogram to evaluate a breast change detected by you or your doctor. During a diagnostic mammogram, the radiologist performing the exam can take additional views to evaluate the area of concern more closely.

Yet mammograms aren't perfect. A certain percentage of breast cancers — sometimes even lumps you can feel — don't show up on X-rays (false-negative result). The rate is higher for women in their 40s. That's because women of this age and younger tend to have denser breasts, making it more difficult to distinguish abnormal from normal tissue.

At other times, mammograms may indicate a problem when none exists (false-positive result). This can lead to unnecessary biopsies, to fear and anxiety, and to increased health care costs. The skill and experience of the radiologist reading the mammogram also have a significant effect on the accuracy of the test results. In spite of these drawbacks, however, most experts agree mammography is the most reliable screening test for most women.

During a mammogram, your breasts are compressed between plastic plates while a radiology technician takes the X-rays. The whole procedure should take less than 30 minutes. You may find mammography somewhat uncomfortable. If you have too much discomfort, inform the technician. If you have tender breasts, schedule your mammogram for a time after your menstrual period. Avoiding caffeine for two days before the test may help reduce breast tenderness.

Also available at some mammography centers is a soft, single-use, foam pad that can be placed on the surface of the compression plates of the mammography machine, making the test less uncomfortable. The pad doesn't interfere with the image quality of the mammogram.

If possible, try to schedule your mammogram around the same time as your annual clinical exam. That way the radiologist can specifically look at any changes your doctor may discover.

Most important, don't let a lack of health insurance keep you from having regular mammograms. Many state health departments and Planned Parenthood clinics offer low-cost or free screenings.

Other tests

• Computer-aided detection (CAD). In traditional mammography, your X-rays are reviewed by a radiologist, whose skill and experience play a large part in determining the accuracy of the test results. In CAD, a computer scans your mammogram after a radiologist has reviewed it. CAD identifies highly suspicious areas on the mammogram, allowing the radiologist to focus on specific spots, but many of these areas may later prove to be normal. Still, using mammography and CAD together may increase the cancer detection rate.
• Digital mammography. In this procedure, an electronic process is used to collect and display X-ray images on a computer screen. This allows your radiologist to alter contrast and darkness, making it easier to identify subtle differences in tissue. In addition, digital images can be transmitted electronically, so women who live in remote areas can have their mammograms read by an expert who is based elsewhere. Digital mammography has been found to be most helpful in evaluating dense breast tissue in women in their 40s.

• Magnetic resonance imaging (MRI). This technique uses a magnet and radio waves to take pictures of the interior of your breast. Although not used for routine screening, MRI can reveal tumors that are too small to detect through physical exams or are difficult to see on conventional mammograms. MRI doesn't take the place of mammograms, but rather is performed as an additional (adjunct) study of the breast.

  MRI isn't recommended for routine screening on women at average risk because it has a high rate of false-positive results, leading to unnecessary anxiety and biopsies. It's also expensive, not readily available and requires interpretation by an experienced radiologist. However, the American Cancer Society now recommends annual screening MRI for women with a lifetime breast cancer risk of 20 percent or higher, women who received chest radiation between ages 10 and 30, and women with a strong family history of breast and ovarian cancers.

  Recent recommendations propose that women with newly diagnosed breast cancer in one breast have a one-time MRI done. MRI can detect breast tumors in the opposite (contralateral) breast missed by mammograms. The test can also detect additional lesions in the affected breast. However, whether finding early tumors in this situation improves treatment outcomes — and deaths from breast cancer — is still unknown.

• Breast ultrasound (ultrasonography). Your doctor may use this technique to evaluate an abnormality seen on a mammogram or found during a clinical exam. Ultrasound uses sound waves to produce images of structures deep within the body. Because it doesn't use X-rays, ultrasound is a safe diagnostic tool that can help determine whether an area of concern is a cyst or solid tissue. But breast ultrasound isn't used for routine screening because it has a high rate of false-positive results — finding problems where none exist.

Experimental procedures

• Ductal lavage. In this procedure, your doctor inserts a tiny, flexible tube (catheter) into the lining of a duct in your breast — the site where most cancers originate — and withdraws a sample of cells. The cells are then examined for precancerous changes that might eventually lead to disease. These changes may show up long before tumors can be detected on a mammogram. But because ductal lavage is a new and invasive procedure, many unknowns remain, including the rate of false-negative results, the exact location in the breast of abnormal cells and whether those cells will necessarily lead to cancer. Clinical trials are being conducted to help find the answers to these questions. In the meantime, ductal lavage isn't recommended as a screening tool.
• Molecular breast imaging (MBI). This experimental technique tracks the movement of a radioactive isotope injected into the bloodstream and taken up by breast tissue, particularly tumors. In preliminary studies, MBI found small tumors that both mammography and ultrasound missed. It's not yet clear how any abnormal findings from MBI could be biopsied, but this is an area of study. Besides requiring some radiation, this imaging method also involves slight compression of the breast. This imaging technique is being studied in women with dense breast tissue and women at high risk of breast cancer. Depending on study results, MBI would most likely become an adjunct to — but not a replacement for — mammography.

Diagnostic procedures
Unlike screening tests, diagnostic procedures help to further characterize breast abnormalities found by some other means, such as by feeling a breast lump or seeing a spot on a mammogram or MRI. These tests help your doctor determine the need for a biopsy and also may be used to help guide a biopsy.

Ultrasound
Ultrasound uses sound waves to create an image of your breast on a computer screen. By analyzing this image, your doctor may be able to tell whether a lump is a cyst or a solid mass. Cysts, which are sacs of fluid, usually aren't cancerous, although your doctor may recommend draining the cyst. If the cyst appears very typical and disappears completely with removal of the fluid, then observation is the only follow-up necessary. If the cyst appears complex, doesn't disappear completely when the fluid is drained or contains bloody fluid, a biopsy is necessary to determine whether cancer is present.

Biopsy
A biopsy — a small sample of tissue removed for analysis in the laboratory — is the only test that can tell if cancer is present. Biopsies can provide important information about an unusual breast change and help determine whether surgery is needed and if so, the type of surgery required. Types of biopsies include:

• Fine-needle aspiration biopsy. Your doctor uses a thin, hollow needle to withdraw tissue from the lump. He or she then sends the tissue to a lab for microscopic analysis. The procedure takes about 30 minutes and is similar to drawing blood. A similar procedure — fine-needle aspiration — is typically performed to remove the fluid from a painful cyst, but it can also help distinguish a cyst from a solid mass.
• Core needle biopsy. A radiologist or surgeon uses a hollow needle to remove tissue samples from a breast lump. As many as 15 samples, each about the size of a grain of rice, may be taken then sent to a pathologist to be analyzed for malignant cells. The advantage of a core needle biopsy is that it removes more tissue for analysis. Sometimes your radiologist or surgeon may use ultrasound to help guide the placement of the needle.
• Stereotactic biopsy. This technique is used to sample and evaluate an area of concern, such as microcalcification, that can be seen on a mammogram but that cannot be felt or seen on an ultrasound. During the procedure, a radiologist takes a core needle biopsy, using your mammogram as a guide. Stereotactic biopsy usually takes about an hour and is performed using local anesthesia.
• Wire localization. Your doctor may recommend this technique when a worrisome lump is seen on a mammogram but can't be felt or evaluated with a stereotactic biopsy. Using your mammogram as a guide, a thin wire is placed in your breast and the tip guided to the lump. Wire localization is usually performed right before a surgical biopsy and is a way to guide the surgeon to the area to be removed and tested.
• Surgical biopsy. This remains one of the most accurate methods for determining whether a breast change is cancerous. During this procedure, your surgeon removes all or part of a breast lump. In general, a small lump will be completely removed (excisional biopsy). If the lump is large, only a sample will be taken (incisional biopsy). The biopsy is generally performed on an outpatient basis in a clinic or hospital.

Estrogen and progesterone receptor tests
Malignant cells removed in a biopsy can be tested for the presence of hormone receptors. If the cancer cells have receptors for estrogen or progesterone or both, your doctor may recommend treatment with a drug such as tamoxifen, which prevents estrogen from binding to these sites.

Staging tests
Staging tests determine the size and location of your cancer and whether it has spread. They also help with treatment planning. Cancer is staged using the numbers 0 through IV.

Stage 0 cancers are also called noninvasive, or in situ (in one place), cancers. Although they don't have the ability to invade normal breast tissue or spread to other parts of your body, it's important to have them removed because they eventually can become invasive cancers.

Stage I to IV cancers are invasive tumors that have the ability to invade normal breast tissue or spread to other areas. A stage I cancer is small and well localized and has a high cure rate. But the higher the stage number, the lower the chances of cure. By stage IV, the cancer has spread beyond your breast to other organs, such as your bones, lungs or liver. Although it's not possible to cure cancer at this stage, it may still respond well to various treatments, which could effectively shrink and control the cancer for an extended period of time.

Genetic tests
If you have a strong family history of breast cancer or other cancers, blood tests may help identify defective BRCA or other genes that are being passed through the family. These tests are often inconclusive and should only be done in select cases after a thorough evaluation with a genetic counselor. Unless you are at high risk of hereditary breast or ovarian cancers, genetic testing usually isn't recommended.

In general, testing is beneficial only if the results will help you make a decision about how you might best reduce your breast or other cancer risk. Options range from lifestyle changes and closer screening and therapy with medications such as tamoxifen to extreme measures such as preventive (prophylactic) bilateral mastectomy and removal of your ovaries (oophorectomy).

Treatment

A diagnosis of breast cancer is one of the most difficult experiences you can face. In addition to coping with a potentially life-threatening illness, you must make complex decisions about treatment.

Talk with your health care team to learn as much as you can about your treatment options. Consider a second opinion from a breast specialist in a breast center or clinic. Talking to other women who have faced the same decision also may help.

Treatments exist for every type and stage of breast cancer. Most women will have surgery and an additional (adjuvant) therapy such as radiation, chemotherapy or hormone therapy. Experimental treatments are also available at cancer treatment centers.

Surgery
Today, radical mastectomy is rarely performed. Instead, the majority of women are candidates for simple mastectomy or lumpectomy. If you decide on mastectomy, you may opt for breast reconstruction.

Breast cancer operations include the following:

• Lumpectomy. This operation saves as much of your breast as possible by removing only the lump plus a surrounding area of normal tissue. Many women can have lumpectomy — often followed by radiation therapy — instead of mastectomy, and in most cases survival rates for both operations are similar. But lumpectomy may not be an option if a tumor is very large, deep within your breast, or if you have already had radiation therapy, have two or more widely separated areas of cancer in the same breast, have a connective tissue disease that makes you sensitive to radiation, or if you have inflammatory breast cancer. If you have a large tumor but still want to consider the possibility of lumpectomy, chemotherapy before surgery may be an option to shrink the tumor and make you eligible for the procedure.

  In general, lumpectomy is almost always followed by radiation therapy to destroy any remaining cancer cells. But when very small, noninvasive cancers are involved, some studies question the role and benefits of radiation therapy — especially for older women. These studies haven't shown that lumpectomy plus radiation prolongs a woman's life any better than does lumpectomy alone.

• Partial or segmental mastectomy. Another breast-sparing operation, partial mastectomy involves removing the tumor as well as some of the breast tissue around the tumor and the lining of the chest muscles that lie beneath it. In almost all cases, you'll have a course of radiation therapy following your operation, similar to if you had a lumpectomy.
• Simple mastectomy. During a simple mastectomy, your surgeon removes all your breast tissue — the lobules, ducts, fatty tissue and skin, including the nipple and areola. Depending on the results of the operation and follow-up tests, you may also need further treatment with radiation to the chest wall, chemotherapy or hormone therapy.
• Modified radical mastectomy. In this procedure, a surgeon removes your entire breast, including the overlying skin, and some underarm lymph nodes (axillary lymph node dissection), but leaves your chest muscles intact. This makes breast reconstruction less complicated.

Sentinel lymph node biopsy
Because breast cancer first spreads to the lymph nodes under the arm, all women with invasive cancer need to have these nodes examined. Rather than remove as many lymph nodes as possible, surgeons now focus on finding the sentinel nodes — the first nodes to receive the drainage from breast tumors and therefore the first place cancer cells will travel. If a sentinel node is removed, examined and found to be normal, the chance of finding cancer in any of the remaining nodes is small and no other nodes need to be removed. This spares many women the need for a more extensive operation and greatly decreases the risk of complications.

Axillary lymph node dissection
If the sentinel lymph node does show the presence of cancer, then your surgeon removes additional lymph nodes in your armpit (axilla). The removal of these lymph nodes does increase the risk of serious arm swelling (lymphedema), but newer surgical techniques make this complication much less likely. Knowing if cancer has spread to the lymph nodes is important in determining the best course of treatment, including whether you'll need chemotherapy or radiation therapy.

Reconstructive surgery
If you want to have breast reconstruction done, discuss this with your surgeon before you have any surgery done. Not all women are candidates for reconstruction. A plastic surgeon can describe the various procedures, show you photos of women who have had different types of reconstruction, and discuss which type of reconstruction might be best in your case. Your options include reconstruction with a synthetic breast implant or reconstruction using your own tissue. These operations can be performed at the time of your mastectomy or at a later date.

• Reconstruction with implants. This technique uses artificial material — silicone gel or saline, in an implantable, leak-proof shell — to replace surgically removed breast tissue. If you don't have enough muscle and skin to cover an implant, your doctor may use a tissue expander, which is an empty implant shell that inflates as fluid is injected. It's placed under your skin and muscle, and your doctor gradually fills it with fluid — usually over a period of several months. When your muscle and skin have stretched enough, the expander is removed and replaced with a permanent implant.
• Reconstruction with a tissue flap. Known as a transverse rectus abdominal muscle (TRAM) flap, this surgery reconstructs your breast using tissue, including fat and muscle, from your abdomen, although surgeons sometimes may use tissue from your back or buttocks instead. Because the procedure is fairly complicated, recovery may take six to eight weeks. Complications include the risk of infection and tissue death. If you have a low percentage of body fat, this type of reconstruction may not be an option for you.
• Deep inferior epigastric perforator (DIEP) reconstruction. In this procedure, fat tissue from your abdomen is used to create a natural-looking breast. But because your abdominal muscles are left intact, you're less likely to experience complications than you are with traditional TRAM flap breast reconstruction. You may also have less pain, and your healing time may be reduced.
• Reconstruction of your nipple and areola. After initial surgery with either tissue transfer or an implant, you may have further surgery to make a nipple and areola. Using tissue from elsewhere in your body, your surgeon first creates a small mound to resemble a nipple. He or she may then tattoo the skin around the nipple to create an areola. Your surgeon may also take a skin graft from elsewhere on your body, place it around the reconstructed nipple to slightly raise the skin and then tattoo the skin graft.

Radiation therapy
Radiation therapy uses high-energy X-rays to kill cancer cells and shrink tumors. It's administered by a radiation oncologist at a radiation center. In general, radiation is the standard of care following a lumpectomy for both invasive and noninvasive breast cancers. Oncologists are also likely to recommend radiation following a mastectomy for a large tumor, for inflammatory breast cancer, for cancer that has invaded the chest wall or for cancer that has spread to more than four lymph nodes in your armpit.

If you won't be receiving chemotherapy, radiation is usually started three to four weeks after surgery. If your doctors recommend chemotherapy, it's usually administered before you undergo radiation therapy. You'll typically receive radiation treatment five days a week for five to six consecutive weeks. The treatments are painless and are similar to getting an X-ray. Each takes about 30 minutes. The effects are cumulative, however, and you may become tired toward the end of the series. Your breast may be pink, puffy and somewhat tender, as if it had been sunburned.

In a small percentage of women, more serious problems may occur, including arm swelling, damage to the lungs, heart or nerves, or a change in the appearance and consistency of breast tissue. Radiation therapy also makes it somewhat more likely that you'll develop another tumor. For these reasons, it's important to learn about the risks and benefits of radiation therapy when deciding between lumpectomy and mastectomy. You may also want to talk to a radiation oncologist about clinical trials investigating shorter courses of radiation or focal application of radiation.

Chemotherapy
Chemotherapy uses drugs to destroy cancer cells. The size of the tumor, characteristics of the cancer cells, and extent of spread of the cancer help determine your need for chemotherapy. If your cancer has a high chance of returning or spreading to another part of your body, your doctor may recommend chemotherapy after surgery to decrease the chance that the cancer will recur. This is known as adjuvant chemotherapy. If your cancer has already spread to other parts of your body, chemotherapy may be recommended to try to control the cancer and decrease any symptoms the cancer is causing.

Treatment often involves receiving two or more drugs in different combinations. These may be administered intravenously, in pill form or both. You may have between four and eight treatments spread over three to six months.

Because chemotherapy affects healthy cells as well as cancerous ones, side effects are common. Your digestive tract, hair and bone marrow — all composed of fast-growing cells — tend to take the brunt of this toxicity, leading to hair loss, nausea, vomiting and fatigue. Not everyone has all of these side effects, however, and methods to control chemotherapy side effects have improved greatly in the past few decades. Notably, more effective drugs are now available to help prevent or reduce nausea and vomiting.

Depending on the chemotherapy drugs your doctor recommends, other side effects may occur, including possible damage to the heart, nerves, kidneys and other organs. Chemotherapy may also temporarily affect your white blood cells — cells that fight off infection.

Another recently described side effect is "chemobrain," the common term for memory and concentration problems that happen to some people during and after chemotherapy. Chemobrain is associated with difficulties involving specific thought processes, including word finding, memory and multitasking.

Premature menopause and infertility also are potential side effects of chemotherapy. The older you are when you begin treatment, the greater the likelihood that your reproductive cycle will be affected. In rare cases, certain chemotherapy medications may lead to cancer of the white blood cells (acute myeloid leukemia) — often years after treatment ends.

Hormone therapy
Hormone therapy — perhaps more properly termed hormone blocking therapy — is often used to treat women whose cancers are sensitive to hormones — estrogen and progesterone receptor positive cancers. Similar to chemotherapy, this form of therapy can be used to decrease the chance of your cancer returning. If the cancer has already spread, hormone therapy may shrink and control it.

Two classes of medications are used in hormone therapy: selective estrogen receptor modulators (SERMs) and aromatase inhibitors.

• Selective estrogen receptor modulators (SERMs). SERMs act by blocking any estrogen present in the body from attaching to the estrogen receptor on the cancer cells, slowing the growth of tumors and killing tumor cells. SERMs can be used in both pre- and postmenopausal women.

  The most common SERM prescribed for hormone therapy is tamoxifen (Nolvadex). Tamoxifen is used as a treatment for women with hormone-sensitive metastatic breast cancer, as an adjuvant therapy for women with early-stage estrogen receptor positive breast cancer, and as a preventive agent in some high-risk women. You take tamoxifen daily, in pill form, for up to five years. It may reduce the risk of recurrence of breast cancer and is less toxic than most anti-cancer drugs.

  But tamoxifen isn't trouble-free. Women taking tamoxifen may experience menopausal symptoms such as night sweats, hot flashes, and vaginal itching, discharge or dryness. More serious side effects, including blood clots and endometrial cancer, occur infrequently. Older women, especially those with other medical conditions, may be at greater risk of more serious side effects than are younger women.

• Aromatase inhibitors. This class of drugs, which includes anastrozole (Arimidex), letrozole (Femara) and exemestane (Aromasin), blocks the conversion of a hormonal substance (androstenedione) into estrogen. This effectively stops estrogen production in cells other than the ovaries. Fat cells, the adrenal gland and other normal cells all make small amounts of estrogen. These drugs are only effective in postmenopausal women.

  In several randomized, controlled trials, women receiving aromatase inhibitors have fared slightly better than have those receiving tamoxifen. Women treated with aromatase inhibitors also had a lower incidence of blood clots and endometrial cancer. To date, the primary drawback of aromatase inhibitors is an increased risk of osteoporosis. The main question about aromatase inhibitors seems to be whether women should take tamoxifen first and then switch to an aromatase inhibitor or simply take an aromatase inhibitor from the start.

Biological therapy
As scientists learn more about the differences between normal cells and cancer cells, treatments aimed at these differences — called biological therapy — are being developed. Three biological therapies are now available for breast cancer. They include:

• Trastuzumab (Herceptin). This FDA-approved biological therapy uses monoclonal antibody technology to attack a protein — called HER2-neu — that's overproduced in about one out of every three breast cancers. By attacking this protein, Herceptin kills cancer cells on its own and in conjunction with chemotherapy or hormone therapy. Herceptin can be used as an adjuvant therapy or to treat advanced disease.
• Bevacizumab (Avastin). Now approved for treating metastatic breast cancer, Avastin also uses monoclonal antibody technology to target new blood vessels and stop them from growing. Cancer cells need to grow new blood vessels in order to survive. This therapy halts that process and kills the cancer cells.
• Lapatinib (Tykerb). Like Herceptin, Tykerb zeros in on and blocks the effects of the HER2 protein. But while Herceptin blocks HER2's action from the outside of the cell, Tykerb is a smaller molecule that works on the inside of the cell. Tykerb works for some women for whom Herceptin is no longer effective. This drug is only approved for use in conjunction with chemotherapy and in women with advanced, metastatic breast cancers.

Clinical trials
Clinical trials are used to test new and promising agents in the treatment of cancer. Clinical trials represent the cutting edge of technology, but they're often unproven treatments that may or may not be superior to currently available therapies. Talk with your doctor about clinical trials to see if one is right for you.

Clinical trials involve more than just new medications. For example, breast surgeons and radiologists are developing nonsurgical methods of destroying cancerous breast tissue. One of these techniques, radiofrequency ablation, uses ultrasound to locate the tumor. Then a metal probe about the size of a toothpick is inserted into the tumor. Inside the tumor, the probe creates heat that destroys cancer cells. Although early tests of radiofrequency ablation have been promising, not all women would be candidates for the procedure if it eventually were approved for widespread use.

Prevention

Nothing guarantees that you won't develop breast cancer. But there are some things you may be able to do to reduce your risk of the disease.

Chemoprevention
Chemoprevention is the use of certain medications to decrease breast cancer risk. Two drugs used for breast cancer prevention in high-risk women come from the class of drugs known as selective estrogen receptor modulators (SERMs):

• Tamoxifen (Nolvadex). Tamoxifen is approved for use as a preventive agent in women age 35 and older who have an elevated risk of developing breast cancer within the next five years. Data from several clinical prevention trials found that tamoxifen use in women at higher than average risk results in a relative risk reduction of about one-third for noninvasive breast cancer and about one-half for invasive breast cancer.

• Raloxifene (Evista). Raloxifene is approved for prevention of invasive breast cancer in postmenopausal women at high risk of the disease, as well as in women with postmenopausal osteoporosis. In the second group, the drug is approved for both breast cancer prevention and osteoporosis treatment. Large clinical trials have also suggested that raloxifene is as effective as tamoxifen in preventing estrogen receptor positive breast cancer in high-risk postmenopausal women who don't have a personal history of breast cancer.

  The Gail model computerized risk assessment is a simple and helpful tool to estimate a woman's risk of developing invasive breast cancer. A five-year Gail model score higher than 1.66 percent is considered high risk. This tool is available online at the National Cancer Institute.

Preventive surgery
Although it's a radical step, preventive surgery also reduces breast cancer risk in high-risk women. Options include:

• Prophylactic mastectomy. This preventive surgery involves removing one or both of your breasts to prevent or reduce your risk of breast cancer. You might consider this option if you're at high risk of breast cancer, you've already had cancer in one breast, you have a family history of breast cancer, you received positive results from genetic testing, or your doctors have identified early signs of cancer in your breast.
• Prophylactic oophorectomy. This preventive option involves surgically removing your ovaries. Although the procedure is usually performed to reduce ovarian cancer risk, having an oophorectomy before you reach menopause also reduces your risk of breast cancer.

Lifestyle factors
Some lifestyle strategies may help reduce breast cancer risk:

• Ask your doctor about aspirin. Taking an aspirin just once a week may help protect against breast cancer, but be sure to talk to your doctor before you start. When used for long periods of time, aspirin can cause stomach irritation, bleeding and ulcers. More serious aspirin side effects include bleeding in the intestinal and urinary tracts and hemorrhagic stroke. In general, you're not a candidate for aspirin therapy if you have a history of ulcers, liver or kidney disease, bleeding disorders, or gastrointestinal bleeding.
• Limit alcohol. Drinking alcohol is strongly linked to breast cancer. The type of alcohol consumed — wine, beer or mixed drinks — seems to make no difference. To help protect against breast cancer, limit the amount of alcohol you drink to less than one drink a day or avoid alcohol completely.
• Maintain a healthy weight. There's a clear link between obesity — weighing more than is appropriate for your age and height — and breast cancer. The association is stronger if you gain the weight later in life, particularly after menopause.
• Avoid long-term hormone therapy. The link between postmenopausal hormone therapy and breast cancer has been a subject of debate for years, partly because research results have been mixed. Estrogen exposure clearly contributes to breast cancer risk, but for most women, the size of the contribution over a lifetime is small — particularly in the absence of other risk factors, such as family history of the disease. If you're approaching menopause and having frequent symptoms, it's probably safe to take hormones for as long as four to five years. Any longer does increase your breast cancer risk, without conferring any clear benefits. The same is true of hormone therapy after age 60.
• Stay physically active. No matter what your age, aim for at least 30 minutes of exercise on most days. Try to include weight-bearing exercises such as walking, jogging or dancing. These have the added benefit of keeping your bones strong.
• Eat foods high in fiber. Try to increase the amount of fiber you eat to between 20 and 30 grams daily — about twice that in an average American diet. Among its many health benefits, fiber may help reduce the amount of circulating estrogen in your body. Foods high in fiber include fresh fruits and vegetables and whole grains.
• Emphasize olive oil. Oleic acid, the main component of olive oil, appears both to suppress the action of the most important oncogene in breast cancer and to increase the effectiveness of the drug Herceptin.
• Avoid exposure to pesticides. The molecular structure of some pesticides closely resembles that of estrogen. This means they may attach to receptor sites in your body. Although studies have not found a definite link between most pesticides and breast cancer, it is known that women with elevated levels of pesticides in their breast tissue have a greater breast cancer risk.

New directions in research
Scientists are investigating a number of potential preventive therapies for breast cancer, including:

• Retinoids. Natural or synthetic forms of vitamin A (retinoids) may have the ability to destroy or inhibit the growth of cancer cells. Unlike other experimental therapies, retinoids may be effective in premenopausal women and in those whose tumors aren't estrogen positive. Research is ongoing.
• Flaxseed. Flaxseed is high in lignan, a naturally occurring compound that lowers circulating estrogens in your body. Flaxseed appears to decrease estrogen production — acting much like tamoxifen does — which may inhibit the growth of breast cancer tumors. Lignans are also antioxidants with weak estrogen-like characteristics. These characteristics may be the mechanism by which flaxseed works to decrease hot flashes. Further research should clarify the connection.

Coping skills

A diagnosis of breast cancer can be overwhelming. It may take some time to sort through all your emotions. But you can still be in charge of your life. You'll have many decisions to make in the weeks and months ahead. The more you know, the better prepared you'll be to make the best choices. As soon as you find out you have breast cancer, start educating yourself about its treatment.

In addition to talking to your medical team — your breast specialist, surgeon, medical oncologist (a specialist in chemotherapy and hormone therapy) and radiation oncologist (a specialist in radiation therapy) — you may also want to talk to a counselor or medical social worker. Or you may find it helpful and encouraging to talk to other women with breast cancer.

There are also excellent books on breast cancer and many reputable resources on the Internet. Be sure to look for the most current information because breast cancer treatments change rapidly.

Telling others
One of your first decisions will likely be how and when to tell those closest to you. If you have children, telling them — no matter what their ages — can be difficult, but honesty is the best approach. You don't have to give all the details. How much and what you say will depend on each child's age and ability to understand. But trying to hide your illness isn't a good idea. Instead, tell your children you're doing everything possible to get well.

The decision to tell friends and co-workers isn't an easy one. Especially in the beginning, you may not want anyone outside your family to know. But over time, you may find it helpful to confide in a few close friends or co-workers.

Keep in mind that people may not always react as you expect. Some may have many of the same feelings you do — anger, fear, grief. Others may be incredibly supportive. And some may not say much at all or may even avoid you. That's not because they don't care, but because they may not know what to say. Let them know that there are no right words and that their concern is enough.

Maintaining a strong support system
More and more studies show that strong relationships are crucial in dealing with life-threatening illnesses. In fact, friends and family are often an integral part of your treatment. Sometimes, though, you may want or need different kinds of support. If so, you may find the concern and understanding of other women with breast cancer especially comforting. Breast cancer survivors have developed a tremendous support network. Your doctor or a medical social worker may be able to put you in touch with a group near you. Or you can contact a cancer organization, such as the American Cancer Society, to find out what's available in your area.

Dealing with intimacy
Western culture places a great emphasis on women's breasts. They're associated with attractiveness, femininity and sexuality. Because of these attitudes, breast cancer may affect your self-image and erode your confidence in intimate relationships. Although it can be difficult, you need to talk to your partner about your concerns — preferably before your surgery.

Taking care of yourself
During your treatment, you'll need to plan your schedule carefully. Allow yourself time to rest. And don't be afraid to ask for help. Your friends and family want to help, but they may not always know what to do. Be specific about your needs. For example, you might ask a friend to pick up your children from school, shop for groceries or prepare meals. If you need to, be prepared to relinquish your role as caretaker for a while. This doesn't mean you're helpless or weak. Far from it. It means you're using all your energy to get well.

At the same time, you'll likely want to stay as independent as possible. Sometimes in their desire to help, other people may try to take over your life. Or they may act as if you're terribly fragile. Both can be detrimental to your recovery. Don't hesitate to tell friends and loved ones how you want to be treated.

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