2INTRODUCTIONBreast cancer, the second-leading cause of cancer deaths in women, is the disease women fear most.Breast cancer can also occur in men, but it's far less common.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.
380% of breast cancers occur in women older than age 50 80% of breast cancers occur in women older than age 50. In 30s, have a one in 233 chance of developing breast cancer. By age 85, chance is one in eight.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.
4SIGNS AND SYMPTOMSWhen the disease is discovered early, 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.Spontaneous clear or bloody discharge from the nipple, often associated with a breast lumpRetraction or indentation of the nippleChange in the size or contours of the breastAny flattening or indentation of the skin over the breast
5Redness or pitting of the skin over breast, like the skin of an orange A number of conditions other than breast cancer can cause the breasts to change in size or feel.Breast tissue changes naturally during pregnancy and the menstrual cycle.Other possible causes of noncancerous (benign) breast changes include fibrocystic changes, cysts, fibroadenomas, infection or injury.If patient haven't yet gone through menopause, may want to wait through one menstrual cycle before seeing the doctor.If the change hasn't gone away after a month, have it evaluated promptly.
6CAUSESIn breast cancer, some of the cells in the breast begin growing abnormally.These cells divide more rapidly than healthy cells do and may spread (metastasize) through the breast, to lymph nodes or to other parts of the 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.
8Only 5-10% 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 will develop breast cancer.
9If one of these genes is present in the family, will 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.
11Each of breasts contains 15 to 20 lobes of glandular tissue, arranged like the petals of a daisy. The lobes are further divided into smaller lobules that produce milk during pregnancy and breast-feeding.Small ducts conduct the milk to a reservoir that lies just beneath the nipple.Supporting this network is a deeper layer of connective tissue called stroma.
12RISK FACTORSSome risk factors, such as age, sex and family history, can't be changedWhereas others, including weight, smoking and a poor diet, are under control.AgePersonal history of breast cancer.Family history.Genetic predisposition.Radiation exposure.Excess weight.ü 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.ü 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.ü 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.ü 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.ü 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.ü 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.
13Early onset of menstrual cycles. Late menopause. First pregnancy at older age.Race.Hormone therapy.Birth control pills.Smoking.Excessive use of alcohol.Precancerous breast changes (atypical hyperplasia, lobular carcinoma in situ).Mammographic breast density.ü 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.ü 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.ü 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.ü 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.ü 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.ü 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.ü 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.ü 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.ü 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.ü 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.
14WHEN TO SEEK MEDICAL ADVICE Although most breast changes aren't cancerous, it's important to have them evaluated promptly.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 the breast.If treated for breast cancer, report any new signs or symptoms immediately.Possible warning signs include a new lump in the breast or a bone ache or pain that doesn't go away after three weeks.When to seek medical adviceAlthough 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 diagnosisScreening — 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:ü 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.ü 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 testsü 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.ü 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.ü 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.ü 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.ü 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.ü 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 proceduresü 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.ü 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:ü 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.ü 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. ü 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.ü 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.ü 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).To perform a breast self-exam, use a circling, massaging motion and follow a clock pattern or a wedge pattern. Alternatively, you can use a sweeping motion to examine breast tissue — sweeping your fingers from the outer part of your breast in toward your nipple.
15Screening 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 age and risk factors, screening may include breast self-examination, examination by nurse or doctor, mammograms (mammography) or other tests.Self breast examination is an option beginning at age 20.
18Mammogram - to check breast tissue Clinical breast examMammogram - to check breast tissueOther testsComputer-aided detection (CAD)Digital mammographyMagnetic resonance imaging (MRI)Breast ultrasound (ultrasonography)Experimental proceduresDuctal lavageMolecular breast imaging (MBI)
22Tamoxifen inhibits estrogen receptor activity AE = antiestrogenicE = estrogenicTamoxifen inhibits estrogen receptor activity in some organs (AE = antiestrogenic) but stimulates estrogen receptor activity in others (E = estrogenic). In organs such as the breast, the AE action of tamoxifen is favorable (+), while in others, such as the brain and vaginal mucosa, it produces unwanted side-effects, and the effect is unfavorable (-). Likewise, in some organs such as bone, the E activity of tamoxifen is favorable (+), while in others, such as the endometrium, it is unfavorable (-). In liver, the E activity is both favorable (lower cholesterol and decreased risk of coronary artery disease) and unfavorable (higher clotting protein levels and increased risk of deep venous thrombosis).
23TREATMENTIn addition to coping with a potentially life-threatening illness – must make complex decisions about treatment.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.
24SURGERY Lumpectomy Partial or segmental mastectomy Simple mastectomy Modified radical mastectomySentinel lymph node biopsyAxillary lymph node dissectionRadiation therapyChemotherapyTreatmentA 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:ü 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.ü 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.ü 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.ü 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.ü 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.
25Reconstructive surgery Reconstruction with implantsReconstruction with a tissue flapDeep inferior epigastric perforator (DIEP) reconstructionReconstruction of the nipple and areolaReconstructive 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.ü 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.ü 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.ü 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.ü 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.
26Selective estrogen receptor modulators (SERMs) Aromatase inhibitors Hormonal therapySelective estrogen receptor modulators (SERMs)Aromatase inhibitorsBiological therapyTrastuzumab (Herceptin)Bevacizumab (Avastin)Lapatinib (Tykerb)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.ü 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.ü 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.ü 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.ü 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.ü 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:ü 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.ü 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.ü 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.
27Chemoprevention Tamoxifen (Nolvadex) Raloxifene (Evista) Preventive surgeryProphylactic mastectomyProphylactic oophorectomyPreventionNothing 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):ü 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.ü 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:ü 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.
28LIFE-STYLE FACTORS Taking aspirin No / limit alcohol Maintain a healthy weightAvoid long-term hormone therapyStay physically activeEat foods high in fiberEmphasize olive oilAvoid exposure to pesticidesLifestyle factors Some lifestyle strategies may help reduce breast cancer risk:ü 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.ü 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.ü 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.ü 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.ü 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.ü 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.ü 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.
29New directions in research Retinoids - Natural or synthetic forms of vit-A have the ability to destroy the growth of cancer cells. Effective in premenopausal women and in those whose tumors aren't estrogen positive.Flaxseed – High in lignan, a naturally occurring compound that lowers circulating estrogens in the body. Decreases estrogen production – acts like tamoxifen – 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 flushes.New directions in research Scientists are investigating a number of potential preventive therapies for breast cancer, including:ü 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.
30COPING SKILLS Telling others Maintaining a strong support system Dealing with intimacySelf-care takingNew directions in research Scientists are investigating a number of potential preventive therapies for breast cancer, including:ü 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.
33BREAST TENDERNESSBreast tenderness is pain or discomfort in the breasts. It is the most common breast symptom women have. It is usually not a sign of breast cancer.Most common cause of breast tenderness is called fibrocystic breast changes.These changes are caused by the swelling of very tiny fluid-filled cysts in fibrous tissue in the breast.The changes usually happen 7-10 days before the menstrual period and go away when period ends.
34CAUSES Puberty (boys / girls) Pregnancy Infection of the breast Hormone imbalance – too much estrogenBirth control pillsBreast-feeding – when breasts engorged (milk)Injury of the breastNoncancerous tumor in the breast (fibroma)Breast cystCondition called hyperprolactinemiaBreast cancer, but often cancer does not cause any pain.Engorged – Absolutely filled: distended with fluid.
35DIAGNOSIS Mammogram (a special x-ray of the breasts) Ultrasound scan of the breasts (a scan with sound waves)Thermography of the breasts (a heat test that outlines the breast in a color pattern)Biopsy (removal of a small piece of tissue or fluid from the breast).Examination of discharge from a nippleBlood test.
36TREATMENT Drink fewer or no beverages with caffeine. Add vitamins E and A to the diet.Reduce salt intake – 1-2 weeks before menstruation.Put heat on the breast with a heating pad or warm water bottle.Diuretics.Surgery is rarely needed.
37SELF-CAREFollow the physician’s recommendations for preventing and treating breast tenderness.Learn how to examine the breasts after the menstrual period every month.
38NIPPLE DISCHARGENipple discharge is any kind of fluid that comes out of the nipple.Nipples contain tiny openings through which fluid can pass.Although most nipple discharge is not serious, any discharge should be evaluated.The color and consistency of the discharge will help in diagnosis.
39A clear, straw-colored discharge sometimes develops in early pregnancy. A whitish or greenish discharge occurring in nonpregnant women is galactorrhea – cause – birth control pills, hormone imbalance, pituitary tumor, or cyst under the areola.Pus discharge indicates a breast infection.
40DIAGNOSIS No menstrual periods Headaches Visual problems. Lab tests of the dischargeBlood testsMammogram (x-ray of the breasts)Ultrasound scan of the breastsCT scan of the brain.
43GALACTORRHEAGalactorrhea is a milklike discharge of fluid from the breast nipples.Usually the discharge is from both breasts rather than just one.A discharge like this is called galactorrhea unless pregnant or breast-feeding.Galactorrhea usually occurs when the body produces too much prolactin. Prolactin is a hormone produced by the pituitary gland. Normally, prolactin helps a woman make milk when she has a baby.
44ETIOLOGY Birth control pills and other medicines Underactive thyroid glandProblems with the pituitary glandSome brain diseases, such as meningitisCyst under the darkened area around the nipple (galactocele)Shingles caused by the chickenpox virus in the chest wallSurgery on the chestOther medical problems – kidney failure, liver disease, sarcoidosis, or Cushing's disease.
45DIAGNOSISMedical history – stopped having menstrual periods, having trouble getting pregnant, or having headaches or vision problems. OTC medicines if any. Sample of the discharge may be tested in the lab.Blood testsMammogram (x-ray of the breasts)Ultrasound scan of the breastsCT scan of the brain to look at the pituitary gland.OTC – Over-the-counter
46TREATMENTIf a galactocele is causing the galactorrhea, the cyst will be removed.If the discharge is caused by drugs, it will clear up when stop taking the drugs. However, stopping drugs is not always necessary.If the galactorrhea is caused by a pituitary gland tumor, needs surgery, radiation, or drug treatments. Can treat with bromocriptine (stops production of prolactin).
47How long will the effects last? Once the cause of the discharge is diagnosed and treated, she should no longer have the discharge. However, if pituitary tumor is present, may need long-term treatment with bromocriptine or radiation because the tumor could come back.SELF-CAREFollow-up tests.Take drugs as prescribed.If the galactorrhea is mild and a cause cannot be found, breast binders can help stop the discharge by preventing stimulation of the nipples.
48PAGET'S DISEASE OF THE NIPPLE Paget's disease is a slowly growing cancer of the nipple. It is a rare form of breast cancer. It mainly affects women and very rarely men.When abnormal cells grow uncontrollably, they are called tumors. It is not known why they occur. In Paget's disease, the tumor starts in the milk ducts of the nipple.
49SYMPTOMSSymptoms seem harmless. It is often thought to be a skin inflammation or infection, which can delay its diagnosis and treatment.Redness, oozing, and crusting of the nipple and the circular, dark area around the nipple (areola), which causes itching and burning.Sore on the nipple that will not heal.Usually only 1 nipple is affected. Sometimes no changes in the skin can be seen. May have a lump in the breast, which may or may not be able to feel.
50DIAGNOSISSample of discharge from the nipple may be examined under a microscope.Biopsy – to remove the sample of breast tissue to test for cancer.Mammogram of both breasts to look for cancer in other parts of the breasts.Ultrasound scan or MRI - both of these tests create pictures of the breasts.
51TREATMENTIf the cancer is only in the nipple and not any other part of the breast:Radiation treatmentsSurgery to remove just the nipple and surrounding tissue.If a mass is found deep in the breast:Surgery to remove all or part of the breastChemotherapy.
52How long will the effects last? Without treatment, the cancerous sore will remain on the nipple and may spread deeper into the breast.PREVENTIONCheck monthly for any lumps, sores, or oozing from the breasts and report any breast changes to the physician right away.
53SORE NIPPLESBreast-feeding should be a comfortable and enjoyable experience.Sore nipples are a common problem among breast-feeding mothers.Often mothers quit nursing their babies early because of sore nipples, but this doesn't have to happen.Sore nipples usually can be prevented or treated.
54Mild nipple discomfort at the beginning of feedings during the first few days of breast-feeding usually needs no treatment.Nipple pain that is severe or lasts throughout a single or for more than a week is not normal and should be evaluated by doctor or a lactation consultant.Protects sore nipples during breast-feedingShaped to allow skin contact with babyMade with odorless, tasteless, ultra-fine siliconeNipple protectors
55CAUSES Position of the baby's mouth on the breast. Size and shape of the nipples and the baby's mouth can affect how the baby latches on the breast.Also, infant's sucking habits can cause nipple discomfort.Other possible causes of nipple pain are an infection of the nipples (yeast or bacterial), breast infection or improper nipple skin care.
56PROBLEMS CAUSEDIf baby is not latching on to the breast correctly, he may not be getting enough milk.Also, nipple pain may cause to put off nursings or not let the baby suck long enough when he nurses.Sucking is important because this is what triggers the milk to begin to flow (let-down reflex).Nipple pain can cause a drop in the milk supply.As a result, baby may not gain weight well.Sore nipples and low milk supply problems often go hand-in-hand.
57TREATMENT Make sure the baby is positioned correctly to nurse Begin a feeding on the less sore nipple to trigger the let-down reflex and start milk flowingFrequent shorter feedings are better than less frequent lengthy feedingsKeep the nipples dryIf any cracks or other breaks in the skin, keep the nipples covered with a soothing ointmentUse a pump to express the milk if the pain is so severe that cannot nurse the babyWatch for signs of a breast infection
58WHEN TO SEEK MEDICAL ADVICE Immediate – following symptoms additional to sore nipples: chills, fever, headache, flu-like symptoms, or pain or redness in the breast.OB/GYN – Nipples sting or burn and have shooting pains in the breast, especially after nursing. Nipple pain keeps from nursing long enough to trigger let-down reflex.Pediatrician – baby unsatisfied after most nursings. Baby may not be satisfied because milk supply is low or baby is not emptying breasts. Nipples – yeast infection, see white patches in the baby's mouth, or baby has had a diaper rash for 3 or more days.