It's hard to hear the news that you have advanced breast cancer. But you can take control of your health by taking an active role in your treatment. The first step is learning about your cancer and your treatment. This brochure can provide some of that information. Today, patients with advanced breast cancer are living longer. This is because there are many treatment options. These include drugs called hormone treatments. They are often used to treat breast cancer.
How does breast cancer develop?
Before knowing how cancer starts, one has to know about the body's cells. Cells are the basic unit of life for all of us. All parts of the human body are made up of them. Normally, our bodies are always making new cells to replace old ones. With breast cancer, a group of breast cells grow and divide too fast. These cells form a lump called a tumour. When the tumour is not found soon enough, the cancer can spread to other parts of the body. One of the first places it may spread to, is the lymph nodes in the armpit.
What makes breast cancer grow?
In many cases, breast cancer needs hormones to grow. One of these hormones is oestrogen. When this is the case, the breast cancer is called oestrogen-dependent. It is also sometimes called oestrogen receptor positive. This type of breast cancer can be treated with hormone treatment. A woman's body makes oestrogen throughout her life.
But, the body makes less after she goes through menopause.
This is the time in life, around age 50, when she stops having monthly periods. How the body makes oestrogen depends on whether a woman has gone through menopause.
If a woman has not yet gone through menopause, oestrogen is produced by the ovaries (female sex glands). In postmenopausal women, oestrogen is produced from other hormones (androgens) and to do this the body uses a protein called aromatase.
Fig. 1: Position of the Lymph Nodes
in relation to the breast
What is the difference between early breast cancer and advanced breast cancer?
The difference between early and advanced breast cancer is how much the cancer has progressed. Cancer is broken down into stages. The stage depends on how big the tumour is and also if the cancer has spread beyond the breast.
Early breast cancer can be at any stage from Stage 0 to Stage 3. In these stages, the cancer has not spread to distant parts of the body. With advanced disease, the cancer can spread to distant parts of the body. When this happens, it is called metastatic breast cancer. Metastatic disease is known as Stage 4.
What is advanced (metastatic) breast cancer?
At this stage, the breast cancer cells move to a new part of the body. The most common areas for breast cancer to spread to are the bones, the lungs, or the liver. When breast cancer cells spread to another body part, it is still called breast cancer. This cancer will still be treated with breast cancer treatments.
What are the signs and symptoms of advanced breast cancer?
The possible signs of advanced breast cancer depend on what part of the body the cancer has spread to. They can include:
|• Bones: aches and weakness|
• Lungs: chest discomfort, shortness of breath, or coughing
• Ovaries: bloating, pain, or vaginal bleeding
• Liver and stomach: abdominal pain and digestion problems
• Brain: seizures, or memory loss, balance, and vision problems
If you have any of these, or other symptoms, please speak to your doctor immediately.
Fig. 2: Areas of the body to
which the breast cancer can spread,
in the advanced stages
How is advanced breast cancer detected?
There are several tests to detect advanced breast cancer. Your doctor will check the area of your body where the cancer first occurred. Then he/she will most likely check your bones, lungs, and liver. These are the places where breast cancer is likely to spread. Below are some of the common tests for people with breast cancer:
• Biopsy - a small sample of cells or tissue is viewed under a microscope. This shows whether the cancer has returned or become worse. It also confirms whether the cancer is the same as the past disease and not new.
• Blood tests - a complete blood count test is done to see if your blood has the right number of cells. These include red and white blood cells and platelets. Red blood cells carry oxygen to parts of the body. White blood cells help to fight infections. Platelets help the blood to clot. Sometimes, people with cancer have too few of these kinds of cells before they get treated. This might be due to the cancer having spread to the bone marrow (where blood cells are made) or elsewhere in the body.
• Bone scan - a special camera is used to take a picture of your bones. It looks for growth or change in the cells that is not normal.
• Chest x-ray - a common test used to spot tumours and looks at major organs.
• CAT scan - an x-ray. It is taken from different angles to give a more detailed picture.
• Hormone receptor test - helps to find out if the cancer uses hormones to grow and if hormone treatment is an option.
• MRI scan - like a CAT scan. It takes detailed pictures of the body. MRIs can take better pictures of the organs than CAT scans.
What are the treatment options for advanced breast cancer?
Today, there are many kinds of treatment options. The kind you receive will depend on:
|• Your age|
• If you have experienced menopause
• If you have had any cancer treatments before
• How far your cancer has spread
• If your cancer will respond to hormone treatment
Be sure to talk to your doctor about what treatments are best for you. Treatments for breast cancer include:
• Surgery - an operation to remove the tumour and the area around it. In some cases with surgery, the breast can be saved. Other times, the whole breast is removed. It depends on the size of the tumour and distribution of the cancer.
• Radiation - high-energy rays (such as x-rays) that kill or shrink cancer cells.
• Chemotherapy ("chemo") - anticancer medicines that destroy cancer cells. This treatment is often given as an infusion in the doctor's practice. The patient then takes a break for a few days or weeks. This depends on the chemo regimen a person gets. This also allows the body to recover from any side effects. Most chemo treatments last from 4 to 6 months. Different treatments may be shorter or longer.
• Hormone treatment - a type of medicine that prevents the body from making or using certain hormones. Most frequently, it is oestrogen. These medicines can slow or stop the growth of cancer. In some cases, the medicines can cause a tumour to shrink.
PLEASE NOTE: Hormone treatment is not the same as hormone replacement therapy (HRT).
What is hormone therapy?
Hormone therapies are medicines (usually tablets) that can be used for treating breast cancer. They have been prescribed for millions of women around the world. Here's how they work:
Many breast cancer tumours need oestrogen to grow.
Oestrogen is a hormone that all women have. In women who have not reached menopause, it is produced mostly in the ovaries. After menopause, or if the ovaries are removed, other parts of the body can still produce oestrogen. Hormone therapies work by keeping oestrogen from reaching the tumour. This can help to slow, or stop the growth of cancer.
Some important differences
Hormone therapy is not chemotherapy. Chemotherapy works by killing the cancer cells throughout the body. Hormone therapy is also not the same as hormone replacement therapy (HRT). The goal of HRT is to increase, rather than lower, a woman's level of certain hormones. This can help to reduce the effects of menopause. Women with breast cancer should consult their doctor or nurse about the role of HRT.
Hormone therapy and how it can affect you
Hormone therapies help many women with cancer every year. There is a good chance that what you gain from therapy, will far outweigh the side effects. Also, know that many side effects will stop when you end your therapy. And knowing what to expect can help you lessen the side effects. Some common side effects of hormone therapy, are discussed below. These include: bone health, hot flushes, cholesterol and sexuality.
Bone health is a concern for women with breast cancer. But there are lots of ways to protect your bones and keep them strong and healthy.
What is bone health?
Your bones need oestrogen to grow and stay healthy. When your body loses oestrogen, the bones sometimes become thin and weak. When this is severe, it is called osteoporosis. It can lead to broken bones, difficulty with movement, or even height loss.
Risks to bone health
There are 3 main reasons why your bones can be at risk:
• Menopause - This is the time in life, around age 50, when a woman stops having periods. At this time, your body also produces less oestrogen. This can lead to thinning bones. In fact, women can lose up to 20% of their bone mass in the first 5 to 7 years after menopause.
• Breast cancer - When cancer spreads, it can invade the bones. This can leave small holes in the bones, or weaken them in other ways. Breast cancer is one of the most common cancers to affect bones.
• Hormone therapy - Some hormone therapies reduce the level of oestrogen in the body. These therapies can also cause more oestrogen loss in a woman who has already gone through menopause. In each case, the woman is at a higher risk for weak or thinning bones.
Not all hormone therapies have the same effect on bones. Some may have less of an impact than others. If you have questions, ask your doctor or nurse.
|Some women are more likely than others to have thinning bones. You may be at risk if you:|
• Are age 65 or older
• Are White or Asian
• Have family members with thinning bones
• Have low levels of oestrogen. This can be caused by menopause, breast cancer and hormone therapy for breast cancer. It can also happen to women whose ovaries have been removed
• Have a small thin body or have become thin because of an illness
• Have received chemotherapy
|• 1 in 3 women over 50 will experience osteoporotic fractures due to weak or thinning bones 1,2,3|
• The lifetime risk of fracture is 30% higher in women than men from age 50 years up 2
• Fractures of the hip, spine, wrist, and other bones occur in women 2
How to measure your bone health - Get a BMD test
This test measures your Bone Mineral Density (BMD). It is painless, fast, and safe. A BMD test shows how thin your bones are, and how quickly you are losing bone mass. It can also indicate whether you are at risk of breaking a bone in the future. Ask your doctor about a BMD test if you:
|• Are under age 65|
• Have experienced menopause
• Have any of the risk factors previously listed or are taking cancer medication that could affect bone health
• Are thinking about getting treatment for thinning bones but first want to know your BMD score
• Have been on hormone replacement therapy (HRT) for a long time and stopped treatment
How to help preserve bone health
Bone loss is painless. So, many women don't know they have a problem until an accident occurs. That's why you should think about your bone health now, before breast cancer hormone therapy begins. Here are some things you can do to prevent or slow down bone thinning.
|• Stay active - Staying active is the best way to build stronger bones. Exercising every day can be beneficial as it may also help you feel better and improve your overall health. Here are some easy and fun ways to keep your body healthy: walking; jogging; climbing stairs and dancing.|
Find an exercise that you enjoy, and do it as often as you can. But keep in mind that you don't have to push yourself too hard. Just stay active! Be sure to talk to your doctor or nurse before starting any exercise programme.
• Eat well - Eating right can have a positive effect on your bone health. Here is some advice known to help strengthen bones:
Be sure to get plenty of calcium in your diet. This mineral, found in many foods, helps to keep bones strong. Women need 1000 to 1500 mg of calcium a day. If you are not getting enough calcium from the foods you eat, you can add it to your diet in other ways or by taking supplements.
Vitamin D should also be part of your diet. It helps the body absorb the calcium you take in. Women need 400 to 800 units of vitamin D a day. You may find a combination of vitamin D and calcium supplements at your health store or pharmacy. Talk to your doctor or nurse about a good diet plan.
Don't smoke or drink too much alcohol. Both tobacco and alcohol are bad for your bones. Limit yourself to no more than 1 alcoholic drink per day.
|These foods are good sources of calcium and vitamin D.|
• Dairy products (milk, cheese, yoghurt, ice cream)
• Green leafy vegetables (dark lettuce, cabbage)
• Foods with calcium added to them (this includes cereals, fruit juices, breakfast bars)
• Dairy products
• Egg yolks
• Saltwater fish
Hot flushes are a common side effect of hormone therapy. But there are ways to help manage this condition and feel better. Do not allow hot flushes to stop therapy. Rather discuss the management of these with your healthcare provider.
What are hot flushes?
A hot flush is a sudden feeling of warmth on your face and upper body. Your skin may get red and your heart may start to race. You may also feel sweaty, scared, anxious, panicked and irritable.
Hot flushes affect women in different ways. They can wake you up at night or keep you from doing the things you like to do. Hot flushes are not bad for your health, but they can affect your quality of life.
Hot flushes are caused by a decrease in the body's oestrogen levels. To make up for this loss, the body tries to "balance" itself. This balancing effort can make the body temperature rise. When the body tries to cool itself, it results in a hot flush.
Many things can lower oestrogen. These include menopause and breast cancer treatment.
• Menopause - Shortly before menopause, a woman's oestrogen levels starts to decrease. Nearly 8 in 10 women have hot flushes during this time.
• Breast cancer treatment - Hormone therapies, as well as chemotherapy, can lower the body's oestrogen levels. Many women get hot flushes as a side effect of these types of therapies.
When to expect hot flushes with hormone therapy
Most women get hot flushes shortly after therapy starts. They often cause the most problems during the first 2 to 3 months of treatment. This depends on the kind of medicine you are taking. After 3 months, the hot flushes often become less intense.
If you are currently suffering from hot flushes, refer to the section on Helpful Tips for handling hot flushes.
Be patient with your hot flushes
Millions of women have overcome hot flushes, and so will you. Just keep in mind that your body is going through changes. Once those changes have taken place, you will feel comfortable with yourself again. Until then, don't be afraid to change the thermostat, or take a break until a hot flush passes. And let your friends and loved ones know what you are going through. Help them understand that a hot flush can make you feel very uneasy. Talking about the problem can make it easier to get the support you need. Whatever you do, don't let hot flushes get in the way of your life!
|During the day or at night, don't let hot flushes get the best of you. Here are some helpful tips you can start using right now!|
• Wear loose clothing. This allows your skin to breathe. Wear a light, sleeveless nightgown to bed
• Wear layers. That way you can take some clothing off during a hot flush
• Wear fabrics such as pure cotton. They soak up sweat and dry quickly. Use only cotton sheets on your bed
• Avoid foods and drinks that may cause hot flushes. These include hot coffee, tea, spicy foods, and alcohol
• When you get a hot flush, splash your face with cold water or take a shower
• Have a cold drink. Be sure to keep a glass of ice water at your side
• Get a folding, hand-held fan that you can flutter in front of your face. Keep it at your bedside at night
• Stay active! Some good ideas are walking, jogging, or dancing
• During the day, keep your house or office under 21°C. At night, keep it under 18°C
• Ask your doctor or nurse about sleep aids or other ways to get a good night's rest
CHOLESTEROL (fat-like chemical)
High cholesterol is a concern for many people, including women with breast cancer. But there are things you can do to control your cholesterol levels. Eating well and staying active may help.
What is cholesterol?
Cholesterol is a kind of fat produced by the body. It is needed for good health, and is found in every cell in the body. But too much of this fat in the blood is not a good thing. It can lead to problems such as heart disease, heart attack, and stroke.
Along with cholesterol, the blood also contains triglycerides This is a chemical form of fat. Too much of it can also lead to problems such as heart disease.
Who is affected by high cholesterol?
After menopause, cholesterol becomes a concern for most women. That's because a woman's blood fat levels often increases at this time. This problem can be made worse by certain hormone therapies. Be sure to ask your doctor or nurse about the effects of different types of therapies.
What to do about high cholesterol
Doctors suggest that all adults should be tested for cholesterol. You should take this test at least every 5 years after the age of 20. If your cholesterol level is too high, you may want to talk to your doctor or nurse about treatment options. And be sure to get tested again!
|These are the fasting cholesterol values to aim for:|
• Total cholesterol: = 5 mmol/litre
• HDL cholesterol (the "good" kind): = 1.2 mmol/litre
• LDL cholesterol (the "bad" kind): = 3 mmol/litre
How to lower your cholesterol
Try a few of these tips to lower your cholesterol.
• Eat less fatty meats, egg yolks, oils, and high-fat dairy products. If you eat meat, try to stick with lean meat and fish
• Eat lots of vegetables, fruits, grains, and low-fat dairy products
• Eat more fibre. It's found in products such as oats, barley, and rice bran
• Stay active! Some good ideas are walking, jogging, or dancing
• If you are overweight, try to lower your weight. It can make a difference
Breast cancer can affect many parts of a woman's life, including her sexuality. But there are ways to keep your sex life healthy and happy. All it takes is a little time and a few helpful tips.
Who is affected by changes in sexuality?
Women with breast cancer may sense changes in their sexual feelings. Surgery, menopause, or chemo can all affect the sexual part of you. As a result, you may have less interest in sex. You also may not enjoy it as much. It is important to know that this is normal. Many women who have had breast cancer have felt this way.
Hormone therapy may play a part
No one knows for sure how hormone therapy affects the sex drive. What is known is that oestrogen plays a big part in sexual function. When a woman loses oestrogen for any reason, it can make sex less enjoyable.
What to do about changes in your sexuality
If you are concerned about your sex life, there are things you can do that may help.
Don't rush yourself
Emotions play a big part in your sex drive. If you don't feel like having sex yet, that's fine. At first, you may just want to be held and feel close to your partner. Once you start to feel confident and comfortable, your interest in sex should return.
|• Ask your doctor or nurse for advice on getting back to an active sex life|
• For vaginal dryness, try water-based products that moisten the skin. Talk to your doctor or nurse
• Give your partner and yourself time to adjust with the changes to your body
• Talk to a counsellor. Your doctor or nurse can help you find one who treats women with breast cancer. It is advisable to take your partner with you
Are there different kinds of hormone treatments?
Yes, there are. For years, breast cancer has been treated with tamoxifen. Tamoxifen was first used in the 70's. It is also the most common treatment for breast cancer. It blocks oestrogen in the breast tissue - preventing oestrogen from helping the cancer cells to grow.
Shortly after tamoxifen was introduced, a different type of hormone treatment started to be used in treating breast cancer. This type of treatment is called aromatase inhibitors - also called AIs. In the past 10 years, stronger AIs have been made. These newer AIs also have fewer side effects than the older ones.
How do aromatase inhibitors (AIs) fight breast cancer?
AIs help to stop the body from making oestrogen. Remember, this hormone is what helps some breast cancer to grow. The body converts another hormone called androgen into oestrogen. To do this, the body uses a protein called aromatase. Androgens "land on" the protein at a place called a receptor site. At this site, androgens are changed to estrogens. AIs block this receptor site on the protein. By keeping out androgen, AIs help to stop oestrogen from being made.
|By reading this booklet, you now know more about your hormone therapy. You have also learned ways to help yourself during treatment.|
If you still have questions or concerns, please talk to your doctor or nurse. Be sure to see our "Words to Know" and "Resources" sections. The more you know, the more you can feel in control of your life! Here are some questions you may want to ask.
• Will the medicine you are prescribing for me affect other conditions I have?
• Will the medicine affect other medicines that I am taking?
• Does the medicine have any side effects I should know about?
• How long will I need to stay on the medicine?
• Does the cancer treatment you are prescribing affect my bone health?
• Do I have other options for treatment?
• Am I at risk for thinning bones due to my family background?
• Does my lifestyle or my medical history put me at risk?
• What can I do to protect my bone health while I'm on breast cancer medicine?
• Should I have a bone mineral density (BMD) test?
• Should I take any medication to help protect my bones while I'm on cancer treatment?
• If I take a medicine to help protect my bones, will taking both medicines at once cause any problems?
• Can I eat certain foods or do certain exercises to help strengthen my bones?
• What will happen if my hot flushes are not treated?
• Can I try a special diet or exercise programme to relieve my hot flushes?
• What kinds of treatments can I take for hot flushes? How long will I need to take them?
• What can I do if hot flushes are waking me up at night?
o What foods should I eat to lower my cholesterol?
• Are there exercises which I can do to help control cholesterol?
• What weight should I be at for the best health?
• Does the breast cancer treatment you are giving me affect my cholesterol?
• What are my fasting cholesterol levels?
• Is there any special medicine I should be taking?
• What can I do to start having an active sex life again?
• Do you know of any good treatments for vaginal dryness?
• Do you know any good counsellors who treat women with breast cancer?
• Is there a breast cancer support group in my area?
A term for cholesterol and triglyceride levels in the body.
BMD (bone mineral density):
A BMD test shows how strong your bones are. It can spot osteoporosis before you have any signs of it.
A drug treatment that kills cancer cells.
Cholesterol is a waxy, fat-like substance that is carried in the blood. It is made in your body by the liver. It is also found in foods that come from animals. These include meats, eggs, and milk products.
A chemical produced by the body, and carried in the bloodstream from one part of the body to another. Hormones control growth, sex, and how the body works. Common hormones include:
o Androgen: A term for any male sex hormone, such as testosterone. It is also found in small amounts in women.
o Oestrogen: A female hormone produced mainly in the ovaries before menopause, and by other tissues afterwards. Oestrogen levels often rise and fall every month before menopause. Oestrogen is what helps a woman develop sexual features such as breasts and hips. It also controls a woman's monthly period and prepares her body for pregnancy. In breast cancer, oestrogen may promote the growth of cancer cells.
o Progesterone: A female hormone released by the ovaries during a woman's monthly period. It gets the body ready for pregnancy and prepares the breasts to produce milk.
Hormone replacement therapy (HRT):
Hormones that are given to women after menopause to replace the ones they have lost. The hormones used in HRT may be androgen, oestrogen, or progesterone.
A cancer treatment that lowers the amount of oestrogen in a woman's body or that stops the cancer from using it. This helps to slow the growth of the tumour.
The time in life when a woman stops having her monthly period. This often happens around the age of 50.
Bone loss, or thinning, that occurs over time. This often leads to broken bones in the hip, spine, or wrist.
|References: 1. Melton LJ, Atkinson EJ, O'Connor MK, O'Fallen WM, Riggs BL. Bone Density and Fracture Risk in Men. J Bone Min Res 1998; 13(12): 1915 - 1924. 2. Melton LJ, Chrischilles EA, Cooper C, Lane AW, Riggs BL. Perspective. How many women have osteoporosis? J Bone Min Res 1992; 7(9): 1005 - 10. 3. Kanis JA, Johnell O, Oden A, et al. Long-Term Risk of Osteoporotic Fracture in Malmö. Osteoporos Int 2000; 11: 669 - 674. |
These resources are learning tools only. They should not replace talking to your doctor or nurse. You and your doctor or nurse should decide what care is best for you.
Cancer Association of South Africa
What every women should know about breast cancer in the new millennium
American Cancer Society
American Society of Clinical Oncology
www.oncology.com or www.asco.org
Cancer Care Inc.
Living Beyond Breast Cancer
The Susan G. Komen Foundation
The Wellness Community
Y-ME National Breast Cancer Organization