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Surgery for breast cancer

Most women with breast cancer have some type of surgery to treat the main breast tumor. The purpose of surgery is to remove as much of the cancer as possible. Surgery can also be done to find out whether the cancer has spread to the lymph nodes under the arm, to restore the breast's shape after a mastectomy, or to relieve symptoms of advanced cancer. Below is a list of some of the most common types of breast cancer surgery.

Breast-conserving surgery

In these types of surgery, only a part of the breast is removed. How much is removed depends on the size and place of the tumor and other factors. It is sometimes called partial (or segmental) mastectomy.

Lumpectomy: This surgery removes only the breast lump and some normal tissue around it. Radiation treatment is usually given after this type of surgery. If chemotherapy is also going to be used, the radiation may be put off until the chemo is finished. If there is cancer at the edge (called the margin) of the piece of tissue that was removed, the surgeon may need to go back and take out more tissue.

Partial (segmental) mastectomy or quadrantectomy: This surgery removes more of the breast tissue than in a lumpectomy (up to one-quarter of the breast). It is usually followed by radiation therapy. But radiation may be delayed if chemotherapy is also going to be given. Side effects of these operations can include pain, short-term swelling, tenderness, and hardness due to scar tissue that forms in the surgical site.

If cancer cells are found at any of the edges of the piece of tissue removed, it is said to have positive margins. When no cancer cells are found at the edges of the tissue, it is said to have negative or clear margins. The presence of positive margins means that that some cancer cells may have been left behind after surgery. If the lab finds positive margins in the tissue removed with surgery, the surgeon may need to go back and remove more tissue. This operation is called a re-excision. If the surgeon can't remove enough breast tissue to get clear margins, a mastectomy may be needed.

The distance from the tumor to the margin is also important. Even if the margins are “clear”, they could be “close” — meaning that the distance between the edge of the tumor and edge of the tissue removed is too small and more surgery may be needed, as well. Surgeons can disagree on what is an adequate (or good) margin.

The more of breast removed, the more likely it is that there will be a change in the shape of the breast afterward. If the breasts look very different after surgery, you might be able to have some type of reconstructive surgery (see the section, "Reconstructive or breast implant surgery"), or have the other breast made smaller so the breasts look more alike. This might even be done during the first surgery. You should talk with your doctor before surgery to get an idea of how your breasts are likely to look afterward, and to learn what your options might be.

For most women with stage I or II breast cancer, breast-conservation therapy (lumpectomy/partial mastectomy plus radiation therapy) works as well as mastectomy. Survival rates of women treated with these 2 approaches are the same.

Mastectomy

Mastectomy is surgery to remove the entire breast. All of the breast tissue is removed, sometimes along with other nearby tissues.

Simple (also called total) mastectomy: In this surgery the entire breast is removed, but not the lymph nodes under the arm or the muscle tissue beneath the breast. Sometimes both breasts are removed, especially when mastectomy is done to try to prevent cancer. If a hospital stay is needed, most women can go home the next day.

For some women who are planning on having reconstruction right away, a skin-sparing mastectomy can be done. For this, most of the skin over the breast (other than the nipple and areola) is left intact. This can work as well as a simple mastectomy. The amount of breast tissue removed is the same as with a simple mastectomy. Although this approach has not been used for as long as the more standard type of mastectomy, many women prefer it because there is less scar tissue and the reconstructed breast seems more natural.

Another option for some women is the nipple-sparing mastectomy. This is like a skin-sparing mastectomy but the nipple and areola are also left behind. This procedure is more often an option for women who have a small early stage cancer near the outer part of the breast, with no signs of cancer in the skin or near the nipple.

There are some problems with nipple-sparing surgeries. Afterward, the nipple does not have a good blood supply, so sometimes it can wither away or become deformed. Because the nerves are also cut, there is little or no feeling left in the nipple. In women with larger breasts, the nipple may look out of place after the breast is reconstructed. As a result, many doctors feel that this surgery is best done in women with small to medium sized breasts.

Modified radical mastectomy: This operation involves removing the entire breast and some of the lymph nodes under the arm.

Radical mastectomy: This is a major operation where the surgeon removes the entire breast, the lymph nodes under the arm (axillary lymph nodes), and the chest wall muscles under the breast. This surgery was once very common, but it is rarely done now because modified radical mastectomy has proven to work just as well. But this operation may still be done for large tumors that are growing into the muscles under the breast.

Possible side effects of breast surgery

Aside from pain after the surgery and the change in the shape of the breast(s), the possible side effects of mastectomy and breast-conserving surgery include wound infection, build-up of blood in the wound, and build-up of clear fluid in the wound. If axillary lymph nodes are also removed, other side effects are possible, such as swelling of the arm and chest (lymphedema).

Choosing between lumpectomy and mastectomy

Many women with early stage cancers can choose between breast-conserving surgery and mastectomy. One advantage of lumpectomy is that it saves the way the breast looks. A downside is that you will need radiation treatment after surgery. This often takes several weeks. On the other hand, some women who have a mastectomy will also need radiation.

When choosing between a lumpectomy and mastectomy, be sure to get all the facts. You may have an initial gut feeling for mastectomy as a way to "take it all out as quickly as possible." This feeling can lead women tend to prefer mastectomy more often than their surgeons do. But the fact is that for most women with stage I or II breast cancer, lumpectomy or partial mastectomy (along with radiation) is as good as mastectomy. There is no difference in the survival rates of women treated with these 2 methods. Other factors, though, can affect which type of surgery is best for you. And lumpectomy is not an option for all women with breast cancer. Your doctor can tell you if there are reasons why a lumpectomy is not right for you.

Lymph nodes surgery

Axillary lymph node dissection: This operation is done to find out whether breast cancer has spread to lymph nodes under the arm. About 10 to 40 (though in most cases less than 20) lymph nodes are removed. If the lymph nodes contain cancer cells, there is a higher chance that cancer cells have also spread through the bloodstream to other parts of the body. Axillary lymph node dissection is usually done at the same time as the mastectomy or lumpectomy, but it can be done in a second operation. This was once the most common way to check for breast cancer spread to nearby lymph nodes, and it is still done in some patients. It can be used as a test to help guide other breast cancer treatment decisions.

Sentinel lymph node biopsy: A sentinel lymph node biopsy is a way of learning whether cancer has spread to the lymph nodes under the arm without removing all of them. For this test, a radioactive substance and/or a dye are injected near the tumor. This is carried by the lymph system to the first nodes, called the sentinel lymph nodes that gets lymph from the tumor. These lymph nodes are the one most likely to contain cancer cells if the cancer has spread. They are then looked at by the pathologist. If the sentinel nodes contain cancer, more lymph nodes may be removed (either right away or in a separate surgery). If they are free of cancer, further lymph node surgery is not usually needed. This type of biopsy calls for a great deal of skill, so it is best to have it done by a team who has experience with it.

Up to now, if the sentinel nodes had cancer, the surgeon would do a full axillary dissection to see how many other lymph nodes were involved. But this may not always be needed. In some cases, it may be just as safe to leave the rest of the lymph nodes behind. Right now, skipping the axillary dissection is only an option for patients having breast conserving surgery (for tumors that are not large) followed by radiation. It is not thought to be an option for patients having a mastectomy.

Side effects: As with other operations, pain, swelling, bleeding, and infection are possible. The main possible long-term effect of lymph node surgery is lymphedema of the arm. This happens in about 3 out of 10 women who have a full axillary lymph node dissection, but is less common after a sentinel lymph node biopsy. Sometimes the swelling lasts for only a few weeks and then goes away. Other times, the swelling comes up later or lasts a long time. Ways to help prevent or reduce the effects of lymphedema are discussed in the section, "Lymphedema." If your arm is swollen, tight, or painful after lymph node surgery, be sure to tell someone on your cancer care team right away.

Reconstructive or breast implant surgery

After having a mastectomy (or some breast-conserving surgeries), a woman may want to think about having the breast rebuilt. These operations are not meant to treat the cancer. They are done to restore the way the breast looks. If you are having breast surgery and are thinking about having breast reconstruction, you should talk to a plastic surgeon before your operation. There are choices to be made, such as when the surgery can be done and exactly what type it will be.

You can get more detailed information about the different types of surgery and their possible side effects in our document, Breast Reconstruction After Mastectomy. You may also find it helpful to talk with a woman who has had the type of reconstruction you are thinking about. Our Reach to Recovery volunteers can help you with this. Call us if you would like to speak to one of these volunteers.

What to expect with surgery

For many people, the thought of surgery can be scary. But knowing what to expect before, during, and afterwards may help ease your fears.

Before surgery: A few days after your biopsy you will know whether or not you have cancer, but the extent of the disease will not be known until after surgery. You will most likely meet with your surgeon a few days before the operation to talk about what will happen. You will be asked to sign a consent form giving the doctor permission to do the surgery. This is a good time to ask any questions you might have.

You may be asked to donate blood ahead of time in case you need it during the surgery. Your doctor will also ask you about medicines, vitamins, or supplements you are taking. You might need to stop taking some of them a week or 2 before surgery.

You will also meet with the health professional who will be giving you the anesthesia (drugs to make you sleep and not feel pain) during your surgery. The type of anesthesia used depends largely on the kind of surgery being done and your medical history.

Surgery: For your surgery, you may be offered the choice of outpatient (where you go home the same day) or you may be stay in the hospital. General anesthesia (you are in a deep sleep) is used for most breast surgeries. You will have an IV line put in (usually into a vein in your arm). It will be used to give medicines that may be needed during the surgery. You will be hooked up to an electrocardiogram (EKG) machine and have a blood pressure cuff on your arm so your heart rhythm and blood pressure can be checked during the surgery.

How long the surgery will take depends on the type of surgery being done. For example, a mastectomy with lymph node removal will take from 2 to 3 hours. After your surgery, you will be taken to the recovery room, where you will stay until you are awake and your vital signs (blood pressure, pulse, and breathing) are stable.

After surgery: The length of your stay in the hospital depends on the type of surgery you had, your overall state of health, whether you have any other medical problems, how well you do during the surgery, and how you feel after the surgery. You and your doctor should decide how long you need to stay in the hospital — not your insurance company. Still, it is important to check your insurance coverage before surgery.

As a rule, women having a mastectomy stay in the hospital for 1 or 2 nights and then go home. But some women may be placed in a 23-hour, short-stay unit before going home.

Less involved operations such as lumpectomy and sentinel lymph node biopsy are usually done on an outpatient basis and an overnight hospital stay is not needed.

After surgery you may have a bandage over the surgery site that wraps snugly around your chest. You may have one or more tubes (drains) from the breast or underarm area to remove fluid that collects during the healing process. You will be taught how to care for the drains. Most drains stay in place for 1 or 2 weeks. Once the flow has gone down to about 1 ounce a day, the drain will be removed.

Most doctors will want you to start moving your arm soon after surgery so that it won't get stiff. Many women who have a lumpectomy or mastectomy are surprised by how little pain they have in the breast area. But they are less happy with the strange feelings (numbness, pinching/pulling) in the underarm area.

Talk with a member of your health care team about what you should do after the surgery to care for yourself. You should get written instructions that will tell you about the following:

• How to take care of the wound and dressing
• How to take care of the drains
• How to know if you have an infection
• When to call the doctor or nurse
• When to begin using the arm and how to do arm exercises to prevent stiffness
• When to start wearing a bra again
• When and how to wear a breast form (sometimes called a prosthesis)
• What to eat and what not to eat
• What medicines to take (including pain medicines and maybe antibiotics)
• What activities you should or should not do
• What feelings you might have about how you look
• When to see your doctor for a follow-up appointment
• Referral to a Reach to Recovery volunteer. Through our Reach to Recovery program, a specially trained volunteer who has had breast cancer can provide information, comfort, and support (see our document, Reach to Recovery for more information).

Most patients see their doctor about 7 to 14 days after the surgery. Your doctor should explain the results of your pathology report and talk to you about whether you will need more treatment.

Pain after breast surgery

Nerve pain after a mastectomy or lumpectomy is called post-mastectomy pain syndrome or PMPS. The signs of PMPS are chest wall pain and tingling down the arm. Pain may also be felt in the shoulder, scar, arm, or armpit. Other common complaints include numbness, shooting or pricking pain, or unbearable itching.

It is important to talk to your doctor about any pain you are having. PMPS can cause you to not use your arm the way you should, and over time you might not be able to use it normally.

PMPS can be treated. Medicines commonly used to treat pain may not work well for nerve pain. But there are other medicines and treatments that do work for this kind of pain. Talk to your doctor to get the pain control you need.

Last Medical Review: 10/12/2011
Last Revised: 03/12/2012

Surgery for male breast cancer

For many, the thought of surgery can be frightening. But with a better understanding of what to expect before, during, and after the operation, many fears can be relieved. Depending on the likely extent of your surgery, you may be offered the choice of an outpatient procedure (you go home the same day) or admission to the hospital.

What to expect

Before surgery: Usually, you meet with your surgeon a few days before the operation to talk about the procedure. This is a good time to ask specific questions about the surgery and review potential risks. Be sure you understand what the extent of the surgery is likely to be and what you should expect afterward.

You will be asked to sign a consent form, giving the doctor permission to perform the surgery. Take your time and review the form carefully to be certain that you understand what you are signing. Sometimes, doctors give you material to look at before your appointment, so you will have plenty of time to read it and won't feel rushed.

You may be asked to donate blood before an operation such as a mastectomy, if the doctor thinks you might need a transfusion during or after the operation. You might feel more secure knowing that if you do need a transfusion, you will get your own blood back. If you do not receive your own blood, it is important to know that in the United States, a blood transfusion from another person is nearly as safe as receiving your own blood. Ask your doctor about your possible need for a blood transfusion.

Your doctor will review your medical records and ask you about any medicines you are taking. This is to be sure that you are not taking anything that could interfere with the surgery. For example, if you are taking aspirin, arthritis medicine, or a blood-thinning medicine (like Coumadin), you may be asked to stop taking it about a week or two before the surgery. Be sure you tell your doctor about everything you take, including vitamins and herbal supplements. Usually, you will be told not to eat or drink anything for 8 to 12 hours before the surgery, especially if you are going to have general anesthesia (will be "asleep" during surgery).

You will also meet with the anesthesiologist or nurse anesthetist, the health professional who will give you the anesthesia during your surgery. The type of anesthesia used depends largely on the kind of surgery being done and your medical history.

Surgery: General anesthesia is usually given whenever the surgery is a mastectomy or an axillary node dissection, and is most often used during breast-conserving surgeries as well. You will have an IV (intravenous) line put in (usually into a vein in your arm), which the medical team will use to give medicines that may be needed during the surgery. Usually you will be hooked up to an electrocardiogram (EKG) machine and have a blood pressure cuff on your arm, so your heart rhythm and blood pressure can be checked during the surgery.

The length of the operation depends on the type of surgery being done. A mastectomy with axillary lymph node dissection often takes from 2 to 3 hours.

What to expect after surgery: After your surgery, you will be taken to the recovery room, where you will stay until you are awake and your condition and vital signs (blood pressure, pulse, and breathing) are stable.

How long you stay in the hospital depends on the surgery being performed, your overall state of health and whether you have any other medical problems, how well you do during surgery, and how you feel after surgery. Decisions about the length of your stay should be made by you and your doctor and not dictated by what your insurance will pay, but it is important to check your insurance coverage before surgery.

Often, men having a mastectomy and/or axillary lymph node dissection stay in the hospital for 1 or 2 nights and then go home. However, it is becoming more common for the surgery to be done as an outpatient, with a short-stay in an observation unit before going home. Your doctor might arrange for a home care nurse to visit you at home to monitor your progress and provide care.

You will have a dressing (bandage) over the surgery site that may or may not snugly wrap around your chest. You may have one or more drains (plastic or rubber tubes) coming out from the breast or underarm area to remove blood and lymph fluid that collects during the healing process. Your health care team will teach you how to care for the drains, which may include emptying and measuring the fluid and identifying problems the doctor or nurse needs to know about. Most drains stay in place for 1 or 2 weeks. When drainage has decreased to about 30 cc (1 fluid ounce) each day, the drain will usually be removed.

Doctors rarely put the arm in a sling to hold it in place. Most doctors will want you to start moving the arm soon after surgery so that it won't get stiff.

Discuss how to care for the surgery site and arm with your health care team. Written instructions about care after surgery are usually given to you and your caregivers. These instructions should include:

• The care of the surgical wound and dressing
• How to monitor drainage and take care of the drains
• How to recognize signs of infection
• When to call the doctor or nurse
• When to begin using the arm and how to do arm exercises to prevent stiffness
• What to eat and not to eat
• Use of medicines, including pain medicines and possibly antibiotics
• Any activity restrictions
• What to expect regarding sensations or numbness in the breast and arm
• When to see your doctor for a follow-up appointment

Most patients see their surgeon within 7 to 14 days after the surgery. Your surgeon should explain the results of your pathology report at this visit and talk to you about the need for further treatment. If you will need more treatment, you will be referred to a radiation oncologist and/or a medical oncologist.

Types of breast surgery

Most men with breast cancer have some type of surgery. This usually involves an operation called a mastectomy. Many cancers may also require axillary (armpit) lymph node sampling and removal.

Mastectomy

A mastectomy removes all of the breast tissue, sometimes along with other nearby tissues.

• In a simple or total mastectomy, the surgeon removes the entire breast, including the nipple, but does not remove underarm lymph nodes or muscle tissue from beneath the breast.
• In a modified radical mastectomy, the surgeon extends the incision to remove the entire breast and lymph nodes under the arm as well.
• If the tumor is large and growing into the chest muscles, the surgeon must do a radical mastectomy, a more extensive operation removing the entire breast, axillary lymph nodes, and the chest wall muscles under the breast. This is only needed if the cancer has grown into the pectoral muscles under the breast.

Breast-conserving surgery

Breast-conserving surgery, such as a lumpectomy (removal of only the breast lump and a surrounding margin of normal tissue), is a treatment option for many women with breast cancer. It is not used as often in men, mainly because the male breast has only a small amount of tissue beneath the nipple. Removing most male breast cancers requires removing almost all of the breast tissue. And because men have less breast tissue, male breast cancers are more likely to have reached the nipple or skin over the breast or the chest wall at an early stage, which requires more extensive surgery. But breast-conserving surgery may be an option in some cases if the tumor is not thought to have reached the nipple. If this type of surgery is done, it is typically followed by radiation therapy.

Possible side effects of breast surgery

Aside from post-surgical pain, temporary swelling, and a change in the appearance of the breast, possible side effects of surgery include bleeding and infection at the surgical site, hematoma (buildup of blood in the wound), and seroma (buildup of clear fluid in the wound).

Lymph node surgery

To determine if the breast cancer has spread to axillary (underarm) lymph nodes, one or more of these lymph nodes may be removed and looked at under the microscope. This is an important part of staging and determining treatment and outcomes. When the lymph nodes are affected, there is an increased likelihood that cancer cells have spread through the bloodstream to other parts of the body.

Axillary lymph node dissection (ALND)

In this procedure, anywhere from about 10 to 40 (though usually less than 20) lymph nodes are removed from the axilla (the area under the arm) and checked for cancer spread. ALND is usually done at the same time as the mastectomy or lumpectomy, but it can be done in a second operation. This was once the most common way to check for breast cancer spread to nearby lymph nodes, and it is still done in some cases. For example, an ALND may be done if one or more of the underarm lymph nodes are known to contain cancer, based on a previous sentinel lymph node biopsy (see below).

Sentinel lymph node biopsy (SLNB)

Although ALND is a safe operation and has low rates of most side effects, removing many lymph nodes increases the chance that the patient will have lymphedema after surgery (this is discussed below). To lower the risk of lymphedema, the doctors may use a sentinel lymph node biopsy (SLNB) procedure to check the lymph nodes for cancer. This procedure tells the doctor if cancer has spread to lymph nodes without removing as many of them first.

In this procedure the surgeon finds and removes the sentinel node (or nodes) — the first lymph node(s) into which a tumor drains, and the one(s) most likely to contain cancer cells if they have started to spread. To do this, the surgeon injects a radioactive substance and/or a blue dye into the area around the tumor, into the skin over the tumor, or into the tissues just under the areola (the colored area around the nipple). Lymphatic vessels will carry these substances into the sentinel node(s) over the next few hours. The doctor can use a special device to detect the radioactivity in the nodes that the radioactive substance flows into or can look for lymph nodes that have turned blue. (These are separate ways to find the sentinel node, but are often done together as a double check.) The doctor then makes an incision (cut) in the skin over the area in the armpit and removes the nodes. These nodes (often 2 or 3) are then looked at by the pathologist.

The lymph node can sometimes be checked for cancer during surgery. If cancer is found in the sentinel lymph node, the surgeon may go on to do a full ALND. If no cancer cells are seen in the lymph node at the time of the surgery, or if the sentinel node is not checked at the time of the surgery, the lymph node(s) will be examined in greater detail over the next several days. If cancer is found in the lymph node, the surgeon may recommend a full ALND at a later time.

If there is no cancer in the sentinel node(s), it's very unlikely that the cancer has spread to other lymph nodes, so no further lymph node surgery is needed. The patient can avoid some of the potential side effects of a full ALND.

Until recently, if the sentinel node(s) contained cancer, the surgeon would do a full axillary lymph node dissection to see how many other lymph nodes were involved. A recent study has shown that this may not always be needed. In some cases, it may be just as safe to leave the rest of the lymph nodes behind. This is based on certain factors, such as the size of the tumor and what treatment is planned after surgery.

A sentinel lymph node biopsy is not always appropriate. If an underarm lymph node looks large or abnormal by touch or by ultrasound, it may be checked by fine needle aspiration. If cancer is found, a full ALND is recommended and a sentinel node biopsy is not needed.

Although this has become a common procedure, sentinel lymph node biopsy is a complex technique that requires a great deal of skill. It should be done only by a surgical team known to have experience with this technique. If you are thinking about having this type of biopsy, ask your health care team if this is something they do regularly.

Possible side effects of lymph node surgery: As with other operations, pain, swelling, bleeding, and infection are possible.

The main possible long-term effect of removing axillary lymph nodes is lymphedema (swelling) of the arm. This occurs because any excess fluid in the arms normally travels back into the bloodstream through the lymphatic system. Removing the lymph nodes sometimes blocks the drainage from the arm, causing this fluid to remain and build up.

This side effect has not been studied well in men, but in studies of women up to 30% of those who have a full ALND develop lymphedema. It also occurs in up to 3% of those who have a sentinel lymph node biopsy. Lymphedema seems to be more common if radiation is given after surgery. Sometimes the swelling lasts for only a few weeks and then goes away. Other times, the swelling lasts a long time. Ways to help prevent or reduce the effects of lymphedema are discussed in the section, "What happens after treatment for breast cancer in men?". If your arm is swollen, tight, or painful after lymph node surgery, be sure to tell someone on your cancer care team right away.

You may also have short- or long-term limitations in moving your arm and shoulder after surgery. This is more common after an ALND than a SLNB. Your doctor may give you exercises to ensure that you do not have permanent problems with movement (a frozen shoulder). Numbness of the skin of the upper, inner arm is another common side effect because the nerve that controls sensation here travels through the lymph node area.

Some patients notice a rope-like structure that begins under the arm and can extend down towards the elbow. This, sometimes called axillary web syndrome or lymphatic cording, is more common after an ALND than SLNB. Symptoms may not appear for weeks or even months after surgery. It can cause pain and limit movement of the arm and shoulder. This often goes away without treatment, although some patients seem to find physical therapy helpful.

Chronic pain after breast surgery

Some patients have problems with nerve (neuropathic) pain in the chest wall, armpit, and/or arm after surgery that doesn’t go away over time. This is called post-mastectomy pain syndrome (PMPS) because it was first described in women who had mastectomies, but it occurs after breast conserving therapy, as well. Studies have shown that between 20% and 30% of women develop symptoms of PMPS after surgery. It isn’t clear how common this is in men after breast cancer surgery. The classic symptoms of PMPS are pain and tingling in the chest wall, armpit, and/or arm. Pain may also be felt in the shoulder or surgical scar. Other common complaints include numbness, shooting or pricking pain, or unbearable itching. Most patients with PMPS say that their symptoms are not severe.

PMPS is thought to be linked to damage done to the nerves in the armpit and chest during surgery. But the causes are not known. It seems to be more common in younger patients, those who had a full ALND (not just a SLNB), and those who were treated with radiation after surgery. Because ALNDs are done less often now, PMPS is less common than it once was.

It is important to talk to your doctor about any pain you are having. PMPS can cause you to not use your arm the way you should and over time you could lose the ability to use it normally.

PMPS can be treated. Although opioids or narcotics are medicines commonly used to treat pain, they don't always work well for nerve pain. But there are medicines and treatments that do work for this kind of pain. Talk to your doctor to get the pain control you need.

Last Medical Review: 09/30/2011
Last Revised: 06/12/2012

Breast Cancer in Men

Most men with breast cancer have some type of surgery. This usually involves an operation called a mastectomy. Many cancers may also require axillary (armpit) lymph node sampling and removal.

Mastectomy

A mastectomy removes all of the breast tissue, sometimes along with other nearby tissues.

• In a simple or total mastectomy, the surgeon removes the entire breast, including the nipple, but does not remove underarm lymph nodes or muscle tissue from beneath the breast.
• In a modified radical mastectomy, the surgeon extends the incision to remove the entire breast and lymph nodes under the arm as well. .
• If the tumor is large and growing into the chest muscles, the surgeon must do a radical mastectomy, a more extensive operation removing the entire breast, axillary lymph nodes, and the chest wall muscles under the breast.

Breast-conserving surgery

Breast-conserving surgery, such as a lumpectomy (removal of only the breast lump and a surrounding margin of normal tissue), is a treatment option for many women with breast cancer. It is not used as often in men, mainly because the male breast has only a small amount of tissue beneath the nipple. Removing most male breast cancers requires removing almost all of the breast tissue. And because men have less breast tissue, male breast cancers are more likely to have reached the nipple or skin over the breast or the chest wall at an early stage, which requires more extensive surgery. But breast-conserving surgery may be an option in some cases if the tumor is not thought to have reached the nipple. If this type of surgery is done, it is typically followed by radiation therapy.

Possible side effects of breast-conserving surgery: Aside from post-surgical pain, temporary swelling, and a change in the appearance of the breast, possible side effects of surgery include bleeding and infection at the surgical site, hematoma (buildup of blood in the wound), and seroma (buildup of clear fluid in the wound).

Axillary lymph node dissection (ALND)

To determine if the breast cancer has spread to axillary (underarm) lymph nodes, some of these lymph nodes may be removed and looked at under the microscope. This is an important part of staging and determining treatment and outcomes. When the lymph nodes are affected, there is an increased likelihood that cancer cells have spread through the bloodstream to other parts of the body.

As noted above, axillary lymph node dissection is part of a radical or modified radical mastectomy procedure. It may also be done along with a breast-conserving procedure, such as lumpectomy. Anywhere from about 10 to 40 lymph nodes are removed.

Whether or not cancer cells are present in the lymph nodes under the arm is an important factor in considering adjuvant therapy. Axillary dissection is used as a test to help guide other breast cancer treatment decisions.

Possible side effects of axillary node dissection: As with other operations, pain, swelling, bleeding, and infection are possible.

The main possible long-term effect of removing axillary lymph nodes is lymphedema (swelling of the arm). This occurs because any excess fluid in the arms normally travels back into the bloodstream through the lymphatic system. Removing the lymph nodes sometimes causes this fluid to remain and build up in the arm. Sometimes the swelling lasts for only a few weeks and then goes away. Other times, the swelling is long lasting.

Certain measures can help prevent or reduce the effects of lymphedema. You can learn about these in a booklet on lymphedema available from the American Cancer Society. If you develop swelling, tightness, or pain at any time in the arm, be sure to tell the nurse or doctor right away.

You may also have short- or long-term limitations in arm and shoulder movement after surgery. Numbness of the upper inner arm skin is another common side effect. This is because of damage to the nerves under the arm and is not related to lymphedema.

Sentinel lymph node biopsy (SLNB)

Lymph node dissection is a safe operation and has low rates of serious side effects, but often doctors may do a sentinel lymph node biopsy instead. This procedure tells the doctor if cancer has spread to lymph nodes without removing all of them first.

In this procedure the surgeon finds and removes the sentinel node (or nodes) -- the first lymph node(s) into which a tumor drains, and the one(s) most likely to contain cancer cells if they have started to spread. To do this, the surgeon injects a radioactive substance and/or a blue dye into the area around the tumor, into the skin over the tumor, or into the tissues just under the areola (the colored area around the nipple). Lymphatic vessels will carry these substances into the sentinel node(s) over the next few hours. The doctor can use a special device to detect the radioactivity in the nodes that the radioactive substance flows into or can look for lymph nodes that have turned blue. (These are separate ways to find the sentinel node, but are often done together as a double check.) The doctor then makes an incision (cut) in the skin over the area in the armpit and removes the nodes. These nodes (often 2 or 3) are then looked at by the pathologist.

If there is no cancer in the sentinel node(s), it's very unlikely that the cancer has spread to other lymph nodes, so no further lymph node surgery is needed. The patient can avoid some of the potential side effects of a full axillary lymph node dissection (see above), but there may still be a small risk of lymphedema.

If the sentinel node(s) contains cancer, the surgeon will usually do a full axillary lymph node dissection to see how many other lymph nodes are involved. This may be done at the same time or several days after the original sentinel node biopsy. The timing depends on how easily the cancer can be seen in the lymph node at the time of surgery. If it is obvious that the sentinel node contains cancer, the surgeon can proceed to the axillary dissection right away. But at other times it may only be found by thorough microscopic study by a pathologist after the SLNB is complete.

A sentinel lymph node biopsy is not always appropriate. If an underarm lymph node appears large or abnormal by touch or by ultrasound, it may be checked by fine needle aspiration. If cancer is found, a sentinel node biopsy is not needed.

Sentinel lymph node biopsy is a complex technique that requires a great deal of skill. It should be done only by a surgical team known to have experience with this technique. If you are thinking about having this type of biopsy, ask your health care team if this is something they do regularly.

Last Medical Review: 01/14/2010
Last Revised: 08/17/2010

Cancer surgery: Physically removing cancer

Cancer surgery: Physically removing cancer

The prospect of cancer surgery may make you feel anxious. Help put your mind at ease by learning more about cancer surgery and how and why it's used.

By Mayo Clinic staff

Cancer surgery — an operation to repair or remove part of your body to diagnose or treat cancer — remains the foundation of cancer treatment. Your doctor may use cancer surgery to achieve any number of goals, from diagnosing and treating your cancer to relieving the symptoms it causes. Cancer surgery may be your only treatment, or it may be supplemented with other treatments, such as radiation, chemotherapy, hormone therapy and biological therapy.

How is cancer surgery used in treatment?

Cancer surgery may be used to achieve one or more goals. Common reasons you might undergo cancer surgery include:

• Cancer prevention. If there's reason to believe that you have a high risk of developing cancer in certain tissues or organs, your doctor may recommend removing those tissues or organs before cancer develops. For example, if you have a genetic condition called familial adenomatous polyposis, your doctor may use cancer surgery to remove your colon and rectum because you have a high risk of developing colon cancer.
• Diagnosis. Your doctor may use a form of cancer surgery to remove all or part of a tumor — allowing the tumor to be studied under a microscope — to determine whether the growth is cancerous (malignant) or noncancerous (benign).
• Staging. Cancer surgery helps your doctor define how advanced your cancer is, called its stage. Surgery allows your doctor to evaluate the size of your tumor and determine whether it's traveled to your lymph nodes. Additional tests might be necessary to gauge your cancer's stage.
• Primary treatment. For many tumors, cancer surgery is the best chance for a cure, especially if the cancer is localized and hasn't spread. If there's evidence that your cancer hasn't spread, your doctor may recommend surgery to remove the cancerous tumor as your primary treatment.
• Debulking. When it's not possible to remove all of a cancerous tumor — for example, because doing so may severely harm an organ — your doctor may remove as much as possible (debulking) in order to make chemotherapy or radiation more effective.
• Relieving symptoms or side effects. Sometimes surgery is used to improve your quality of life rather than to treat the cancer itself — for example, to relieve pain caused by a tumor that's pressing on a nerve or bone or to remove a tumor that's blocking your intestine.

Surgery is often combined with other cancer treatments, such as chemotherapy and radiation. Whether you opt to undergo additional cancer treatment depends on your type of cancer and its stage.

How is cancer surgery traditionally performed?

	Lumpectomy
	Modified radical mastectomy
	Lung cancer surgery

Traditionally, the primary purpose of cancer surgery is to cure your cancer by removing all of it from your body. The surgeon usually does this by cutting into your body and removing the cancer along with some surrounding healthy tissue to ensure that all of the cancer is removed. Your surgeon may also remove some lymph nodes in the area to determine if the cancer has spread. This helps your doctor assess the chance of your being cured, as well as the need for further treatment.

In the case of breast cancer surgery, your doctor may remove the cancer by removing the whole breast (mastectomy) or by removing only the portion of your breast that contains the cancer and some of the surrounding tissue (lumpectomy). In the case of lung cancer surgery, your doctor may remove part of one lung (lobectomy) or the entire lung (pneumonectomy) in an attempt to ensure that all the cancer has been removed.

What other techniques are used in cancer surgery?

Many other types of surgical methods for treating cancer and precancerous conditions exist, and investigators continue to research new methods. Some common types of cancer surgery include:

• Cryosurgery. During this type of surgery, your doctor uses very cold material, such as liquid nitrogen spray or a cold probe, to freeze and destroy cancer cells or cells that may become cancerous, such as irregular cells in a woman's cervix that could become cervical cancer.
• Electrosurgery. By applying high-frequency electrical currents, your doctor can kill cancer cells, for example, in your mouth or on your skin.
• Laser surgery. Laser surgery, used to treat many types of cancer, uses beams of high-intensity light to shrink or vaporize cancer cells.
• Mohs surgery. Useful for removing cancer from certain sensitive areas of the skin, such as near the eye, and for assessing how deep a cancer goes, this method of surgery involves carefully removing cancer layer by layer with a scalpel. After removing a layer, your doctor evaluates it under a microscope, continuing in this manner until all the abnormal cells have been removed and the surrounding tissue shows no evidence of cancer.
• Laparoscopic surgery. A surgeon uses a laparoscope to see inside your body without making large incisions. Instead, several small incisions are made and a tiny camera and surgical tools are inserted into your body. The surgeon watches a monitor that projects what the camera sees inside your body. The smaller incisions mean faster recovery and a reduced risk of complications. Laparoscopic surgery is used in cancer diagnosis, staging, treatment and symptom relief.
• Robotic surgery. In robotic surgery, the surgeon sits away from the operating table and watches a screen that projects a 3-D image of the area being operated on. The surgeon uses hand controls that tell a robot how to maneuver surgical tools to perform the operation. Robotic surgery helps the surgeon operate in hard-to-reach areas.
• Natural orifice surgery. Natural orifice surgery is currently being studied as a way to operate on organs in the abdomen without cutting through the skin. Instead, surgeons pass surgical tools through a natural body opening, such as your mouth, rectum or vagina. As an example, a surgeon might pass surgical tools down your throat and into your stomach during natural orifice surgery. A small incision is made in the wall of the stomach and surgical tools pass into the abdominal cavity in order to take a sample of liver tissue or remove your gallbladder. Natural orifice surgery is experimental, and few operations have been performed this way. Doctors hope it can reduce the risk of infection, pain and other complications of surgery.

Cancer surgery continues to evolve. Researchers are investigating other surgical techniques with a goal of less invasive procedures.

What can you expect before and after cancer surgery?

Preparation and healing from cancer surgery varies greatly based on the operation. But in general, you can expect certain similarities, including:

• Preparation. In general, expect to undergo certain tests, such as blood tests, urine tests, X-rays and other imaging tests, in the days preceding your surgery. These tests will help your doctor assess your surgical needs, such as your blood type should you need a transfusion, and identify potential risks, such as infections, that may influence your surgery.
• Anesthesia. If you're having surgery, you'll likely need some type of anesthetic - a medication that blocks the perception of pain. Your options for anesthesia will be based on what type of surgery you're receiving.
• Recovery. Depending on your surgery, you may stay in the hospital for a time before going home. Your health care team will give you specific directions for your recovery, such as how to care for any wounds, what foods or activities to avoid and what medications to take.

What are the risks of cancer surgery?

As with any surgery, cancer surgery does carry risks. What side effects you might experience after cancer surgery will depend on your specific surgery. In general, most cancer operations carry a risk of:

• Pain. Pain is a common side effect of most operations. Some cause more pain than others do. Your health care team will tell you how to keep your pain to a minimum and will provide medications to reduce or eliminate the pain.
• Infection. The site of your surgery can become infected. Your health care team will show you how to care for your wound after surgery. Follow this routine closely to avoid infection, which can lengthen your recovery time after surgery. Doctors treat infections most often with antibiotics.
• Loss of organ function. In order to remove your cancer, the surgeon may need to remove an entire organ. For example, a kidney may need to be removed (nephrectomy) if you have kidney cancer. For some such operations, the remaining organ can function sufficiently to compensate for the loss, but in other situations you may be left with impairments. For instance, removal of a lung (pneumonectomy) may cause difficulty breathing.
• Bleeding. All operations carry a risk of bleeding. Your surgeon will try to minimize this risk.
• Blood clots. While you're recovering from surgery, you're at an increased risk of developing a blood clot. Though the risk is small, this complication can be serious. Blood clots most commonly occur in the legs and may cause some swelling and pain. A blood clot that breaks off and travels to a lung is called a pulmonary embolism, a dangerous and sometimes deadly condition. Your surgeon will take precautions to prevent blood clots from developing, such as getting you up and out of bed as soon as possible after your operation or prescribing a blood-thinning medication to reduce the risk of a clot.
• Altered bowel and bladder function. Immediately after your surgery, you may experience difficulty having a bowel movement or emptying your bladder. This typically resolves in a few days, depending on your specific operation.

Whatever cancer treatment your doctor recommends, you're likely to feel some anxiety about your condition and the treatment process. Knowing what to expect can help. Use this information to help you ask informed questions when you meet with your doctor.

References

1. Niederhuber JE. Surgical interventions in cancer. In: Abeloff MD, et al. Abeloff's Clinical Oncology. 4th ed. Philadelphia, Pa.: Churchill Livingstone Elsevier; 2008:407.
2. Surgery. American Cancer Society. http://www.cancer.org/Treatment/TreatmentsandSideEffects/TreatmentTypes/Surgery/index?sitearea=ETO&vie. Accessed June 9, 2011.
3. Khashab MA, et al. Natural orifice translumenal endoscopic surgery. Current Opinion in Gastroenterology. 2010;26:471.
4. Gomez G. Emerging technology in surgery: Informatics, electronics, robotics. In: Townsend CM Jr, et al. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 18th ed. Philadelphia, Pa.: Saunders Elsevier; 2008. http://www.mdconsult.com/das/book/body/208746819-6/0/1565/0.html. Accessed June 10, 2011.

© 1998-2012 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only. "Mayo," "Mayo Clinic," "MayoClinic.com," "EmbodyHealth," "Enhance your life," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research.

Hormone Therapy for Breast Cancer

Key Points

• The hormones estrogen and progesterone can stimulate the growth of some breast cancers. Hormone therapy is used to stop or slow the growth of these tumors.
• Hormone therapy is used to treat both early and advanced breast cancer, and to prevent breast cancer in women who are at high risk of developing the disease.
• Certain medications, especially antidepressants, may reduce the potency of the hormone therapy drug tamoxifen. People who are taking antidepressants should discuss this issue with their doctor.

1. What are hormones?

   Hormones are substances that function as chemical messengers in the body. They affect the actions of cells and tissues at various locations in the body, often reaching their targets through the bloodstream.

   The hormones estrogen and progesterone are produced by the ovaries in premenopausal women and by some other tissues, including fat and skin, in both premenopausal and postmenopausal women. Estrogen promotes the development and maintenance of female sex characteristics and the growth of long bones. Progesterone plays a role in the menstrual cycle and pregnancy.

   Estrogen and progesterone can also promote the growth of some breast cancers, which are called hormone-sensitive (or hormone-dependent) breast cancers.

2. How do hormones stimulate the growth of breast cancer?

   Hormone-sensitive breast cancer cells contain proteins known as hormone receptors that become activated when hormones bind to them. The activated receptors cause changes in the expression of specific genes, which can lead to the stimulation of cell growth.

   To determine whether breast cancer cells contain hormone receptors, doctors test samples of tumor tissue that have been removed by surgery. If the tumor cells contain estrogen receptors, the cancer is called estrogen receptor-positive (ER-positive), estrogen-sensitive, or estrogen-responsive. Similarly, if the tumor cells contain progesterone receptors, the cancer is called progesterone receptor-positive (PR- or PgR-positive). Approximately 70 percent of breast cancers are ER-positive. Most ER-positive breast cancers are also PR-positive (1).

   Breast cancers that lack estrogen receptors are called estrogen receptor-negative (ER-negative). These tumors are estrogen-insensitive, meaning that they do not use estrogen to grow. Breast tumors that lack progesterone receptors are called progesterone receptor-negative (PR- or PgR-negative).

3. What is hormone therapy?

   Hormone therapy (also called hormonal therapy, hormone treatment, or endocrine therapy) slows or stops the growth of hormone-sensitive tumors by blocking the body’s ability to produce hormones or by interfering with hormone action. Tumors that are hormone-insensitive do not respond to hormone therapy.

   Hormone therapy for breast cancer is not the same as menopausal hormone therapy or female hormone replacement therapy, in which hormones are given to reduce the symptoms of menopause.

4. What types of hormone therapy are used for breast cancer?

   Several strategies have been developed to treat hormone-sensitive breast cancer, including the following:

   Blocking ovarian function: Because the ovaries are the main source of estrogen in premenopausal women, estrogen levels in these women can be reduced by eliminating or suppressing ovarian function. Blocking ovarian function is called ovarian ablation.

   Ovarian oblation can be done surgically in an operation to remove the ovaries (called oophorectomy) or by treatment with radiation. This type of ovarian ablation is usually permanent.

   Alternatively, ovarian function can be suppressed temporarily by treatment with drugs called gonadotropin-releasing hormone (GnRH) agonists, which are also known as luteinizing hormone-releasing hormone (LH-RH) agonists. These medicines interfere with signals from the pituitary gland that stimulate the ovaries to produce estrogen.

   Examples of ovarian suppression drugs that have been approved by the U.S. Food and Drug Administration (FDA) are goserelin (Zoladex®) and leuprolide (Lupron®).

   Blocking estrogen production: Drugs called aromatase inhibitors can be used to block the activity of an enzyme called aromatase, which the body uses to make estrogen in the ovaries and in other tissues. Aromatase inhibitors are used primarily in postmenopausal women because the ovaries in premenopausal women produce too much aromatase for the inhibitors to block effectively. However, these drugs can be used in premenopausal women if they are given together with a drug that suppresses ovarian function.

   Examples of aromatase inhibitors approved by the FDA are anastrozole (Arimidex®) and letrozole (Femara®), both of which temporarily inactivate aromatase, and exemestane (Aromasin®), which permanently inactivates the enzyme.

   Blocking estrogen’s effects: Several types of drugs interfere with estrogen’s ability to stimulate the growth of breast cancer cells:

   • Selective estrogen receptor modulators (SERMs) bind to estrogen receptors, preventing estrogen from binding. Examples of SERMs approved by the FDA are tamoxifen (Nolvadex®), raloxifene (Evista®), and toremifene (Fareston®). Tamoxifen has been used for more than 30 years to treat hormone receptor-positive breast cancer.
     
     Because SERMs bind to estrogen receptors, they can potentially not only block estrogen activity (i.e., serve as estrogen antagonists) but also mimic estrogen effects (i.e., serve as estrogen agonists). Most SERMs behave as estrogen antagonists in some tissues and as estrogen agonists in other tissues. For example, tamoxifen blocks the effects of estrogen in breast tissue but acts like estrogen in the uterus and bone.
   • Other antiestrogen drugs, such as fulvestrant (Faslodex®), work in a somewhat different way to block estrogen’s effects. Like SERMs, fulvestrant attaches to the estrogen receptor and functions as an estrogen antagonist. However, unlike SERMs, fulvestrant has no estrogen agonist effects. It is a pure antiestrogen. In addition, when fulvestrant binds to the estrogen receptor, the receptor is targeted for destruction.

5. How is hormone therapy used to treat breast cancer?

   There are three main ways that hormone therapy is used to treat hormone-sensitive breast cancer:

   Adjuvant therapy for early-stage breast cancer: Research has shown that women treated for early-stage ER-positive breast cancer benefit from receiving at least 5 years of adjuvant hormone therapy (2). Adjuvant therapy is treatment given after the main treatment (surgery, in the case of early-stage breast cancer) to increase the likelihood of a cure.

   Adjuvant therapy may include radiation therapy and some combination of chemotherapy, hormone therapy, and targeted therapy. Tamoxifen has been approved by the FDA for adjuvant hormone treatment of premenopausal and postmenopausal women (and men) with ER-positive early-stage breast cancer, and anastrozole and letrozole have been approved for this use in postmenopausal women.

   A third aromatase inhibitor, exemestane, is approved for adjuvant treatment of early-stage breast cancer in postmenopausal women who have received tamoxifen previously.

   Until recently, most women who received adjuvant hormone therapy to reduce the chance of a breast cancer recurrence took tamoxifen every day for 5 years. However, with the advent of newer hormone therapies, some of which have been compared with tamoxifen in clinical trials, additional approaches to hormone therapy have become common (3–5). For example, some women may take an aromatase inhibitor every day for 5 years, instead of tamoxifen. Other women may receive additional treatment with an aromatase inhibitor after 5 years of tamoxifen. Finally, some women may switch to an aromatase inhibitor after 2 or 3 years of tamoxifen, for a total of 5 or more years of hormone therapy.

   Decisions about the type and duration of adjuvant hormone therapy must be made on an individual basis. This complicated decision-making process is best carried out by talking with an oncologist, a doctor who specializes in cancer treatment.

   Treatment of metastatic breast cancer: Several types of hormone therapy are approved to treat hormone-sensitive breast cancer that is metastatic (has spread to other parts of the body).

   Studies have shown that tamoxifen is effective in treating women and men with metastatic breast cancer (6). Toremifene is also approved for this use. The antiestrogen fulvestrant can be used in postmenopausal women with metastatic ER-positive breast cancer after treatment with other antiestrogens (7).

   The aromatase inhibitors anastrozole and letrozole can be given to postmenopausal women as initial therapy for metastatic hormone-sensitive breast cancer (8, 9). These two drugs, as well as the aromatase inhibitor exemestane, can also be used to treat postmenopausal women with advanced breast cancer whose disease has worsened after treatment with tamoxifen (10).

   Neoadjuvant treatment of breast cancer: The use of hormone therapy to treat breast cancer before surgery (neoadjuvant therapy) has been studied in clinical trials (11). The goal of neoadjuvant therapy is to reduce the size of a breast tumor to allow breast-conserving surgery. Data from randomized controlled trials have shown that neoadjuvant hormone therapies—in particular, aromatase inhibitors—can be effective in reducing the size of breast tumors in postmenopausal women. The results in premenopausal women are less clear because only a few small trials involving relatively few premenopausal women have been conducted thus far.

   No hormone therapy has yet been approved by the FDA for the neoadjuvant treatment of breast cancer.

6. Can hormone therapy be used to prevent breast cancer?

   Yes. Most early breast cancers are ER-positive, and clinical trials have studied whether hormone therapy can be used to prevent breast cancer in women who are at increased risk of getting the disease.

   A large NCI-sponsored randomized clinical trial called the Breast Cancer Prevention Trial found that tamoxifen, taken for 5 years, reduced the risk of developing invasive breast cancer by about 50 percent in postmenopausal women who were at increased risk of getting the disease (12). A subsequent large randomized trial, the Study of Tamoxifen and Raloxifene, which was also sponsored by NCI, found that 5 years of raloxifene reduces breast cancer risk in such women by about 38 percent (13).

   As a result of these trials, both tamoxifen and raloxifene have been approved by the FDA to reduce the risk of developing breast cancer in women at high risk of the disease. Tamoxifen is approved for use regardless of menopausal status. Raloxifene is approved for use only in postmenopausal women.

   The aromatase inhibitor exemestane has also been found to reduce the risk of breast cancer in postmenopausal women at increased risk of the disease. After 3 years of follow-up in another randomized trial, women who took exemestane were 65 percent less likely than those who took a placebo to develop breast cancer (14). Longer follow-up studies will be necessary to determine whether the risk reduction with exemestane remains high over time, as well as to understand any risks of exemestane treatment. Although exemestane has been approved by the FDA for treatment of women with ER-positive breast cancer, it has not been approved for breast cancer prevention.

7. What are the side effects of hormone therapy?

   The side effects of hormone therapy depend largely on the specific drug or the type of treatment (5). The benefits and risks of taking hormone therapy should be carefully weighed for each woman.

   Hot flashes, night sweats, and vaginal dryness are common side effects of hormone therapy. Hormone therapy also disrupts the menstrual cycle in premenopausal women.

   Less common but serious side effects of hormone therapy drugs are listed below.

   Tamoxifen

   • Risk of blood clots, especially in the lungs and legs (12)
   • Stroke (15)
   • Cataracts (16)
   • Endometrial and uterine cancers (15, 17)
   • Bone loss in premenopausal women
   • Mood swings, depression, and loss of libido
   • In men: headaches, nausea, vomiting, skin rash, impotence, and decreased sexual interest

   Raloxifene

   • Risk of blood clots, especially in the lungs and legs (12)
   • Stroke in certain subgroups (15)
   • Bone loss

   Ovarian suppression

   • Cardiovascular side effects
   • Bone loss
   • Mood swings, depression, and loss of libido

   Aromatase inhibitors

   • Risk of heart attack, angina, heart failure, and hypercholesterolemia (18)
   • Bone loss
   • Joint pain (19–22)
   • Mood swings, depression, and loss of libido

   Fulvestrant

   • Risk of blood clots
   • Bone loss
   • Joint pain
   • Gastrointestinal symptoms (23)
   • Loss of strength (23)

   A common switching strategy, in which patients take tamoxifen for 2 or 3 years, followed by an aromatase inhibitor for 2 or 3 years, may yield the best balance of benefits and harms of these two types of hormone therapy (15).

8. Can other drugs interfere with hormone therapy?

   Certain drugs, including several commonly prescribed antidepressants (those in the category called selective serotonin reuptake inhibitors, or SSRIs), inhibit an enzyme called CYP2D6. This enzyme plays a critical role in the use of tamoxifen by the body because it metabolizes, or breaks down, tamoxifen into molecules, or metabolites, that are much more active than tamoxifen itself.

   The possibility that SSRIs might, by inhibiting CYP2D6, slow the metabolism of tamoxifen and reduce its potency is a concern given that as many as one-fourth of breast cancer patients experience clinical depression and may be treated with SSRIs. In addition, SSRIs are sometimes used to treat hot flashes caused by hormone therapy.

   Researchers have found that women taking certain SSRIs together with tamoxifen have decreased blood levels of active tamoxifen metabolites. Because of this, many experts suggest that patients who are taking antidepressants along with tamoxifen should discuss treatment options with their doctors. For example, doctors may recommend switching from an SSRI that is a potent inhibitor of CYP2D6 (such as paroxetine) to one that is a weaker inhibitor (such as sertraline) or that has no inhibitory activity (such as venlafaxine or citalopram), or they may suggest that their postmenopausal patients take an aromatase inhibitor instead of tamoxifen.

   Other medications that inhibit CYP2D6 include the following:

   • Quinidine, which is used to treat abnormal heart rhythms
   • Diphenhydramine, which is an antihistamine
   • Cimetidine, which is used to reduce stomach acid

   People who are prescribed tamoxifen should discuss the use of all other medications with their doctors.

9. Where can someone find more information about drugs used in hormone therapy for breast cancer?

   NCI's Drug Information Summaries provide consumer-friendly information about certain drugs that are approved by the FDA to treat cancer or conditions related to cancer. For each drug, topics covered include background information, research results, possible side effects, FDA approval information, and ongoing clinical trials. The Drug Information Summaries include information about drugs that have been approved for breast cancer.

Selected References

1. Dunnwald LK, Rossing MA, Li CI. Hormone receptor status, tumor characteristics, and prognosis: a prospective cohort of breast cancer patients. Breast Cancer Research 2007; 9(1):R6.

   [PubMed Abstract]

2. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Relevance of breast cancer hormone receptors and other factors to the efficacy of adjuvant tamoxifen: patient-level meta-analysis of randomised trials. Lancet 2011; 378(9793)771–784.

   [PubMed Abstract]

3. Untch M, Thomssen C. Clinical practice decisions in endocrine therapy. Cancer Investigation 2010; 28 Suppl 1:4–13.

   [PubMed Abstract]

4. Regan MM, Neven P, Giobbie-Hurder A, et al. Assessment of letrozole and tamoxifen alone and in sequence for postmenopausal women with steroid hormone receptor-positive breast cancer: the BIG 1–98 randomised clinical trial at 8.1 years median follow-up. Lancet Oncology 2011; 12(12):1101–1108.

   [PubMed Abstract]

5. Burstein HJ, Griggs JJ. Adjuvant hormonal therapy for early-stage breast cancer. Surgical Oncology Clinics of North America 2010; 19(3):639–647.

   [PubMed Abstract]

6. Sawka CA, Pritchard KI, Shelley W, et al. A randomized crossover trial of tamoxifen versus ovarian ablation for metastatic breast cancer in premenopausal women: a report of the National Cancer Institute of Canada Clinical Trials Group (NCIC CTG) trial MA.1. Breast Cancer Research and Treatment 1997; 44(3):211–215.

   [PubMed Abstract]

7. Howell A, Pippen J, Elledge RM, et al. Fulvestrant versus anastrozole for the treatment of advanced breast carcinoma: a prospectively planned combined survival analysis of two multicenter trials. Cancer 2005; 104(2):236–239.

   [PubMed Abstract]

8. Cuzick J, Sestak I, Baum M, et al. Effect of anastrozole and tamoxifen as adjuvant treatment for early-stage breast cancer: 10-year analysis of the ATAC trial. Lancet Oncology 2010; 11(12):1135–1141.

   [PubMed Abstract]

9. Mouridsen H, Gershanovich M, Sun Y, et al. Phase III study of letrozole versus tamoxifen as first-line therapy of advanced breast cancer in postmenopausal women: analysis of survival and update of efficacy from the International Letrozole Breast Cancer Group. Journal of Clinical Oncology 2003; 21(11):2101–2109.

   [PubMed Abstract]

10. Mauri D, Pavlidis N, Polyzos NP, Ioannidis JP. Survival with aromatase inhibitors and inactivators versus standard hormonal therapy in advanced breast cancer: meta-analysis. Journal of the National Cancer Institute 2006; 98(18):1285–1291.

    [PubMed Abstract]

11. Chia YH, Ellis MJ, Ma CX. Neoadjuvant endocrine therapy in primary breast cancer: indications and use as a research tool. British Journal of Cancer 2010; 103(6):759–764.

    [PubMed Abstract]

12. Vogel VG, Costantino JP, Wickerham DL, et al. Effects of tamoxifen vs raloxifene on the risk of developing invasive breast cancer and other disease outcomes: the NSABP Study of Tamoxifen and Raloxifene (STAR) P–2 trial. JAMA 2006; 295(23):2727–2741.

    [PubMed Abstract]

13. Vogel VG, Costantino JP, Wickerham DL, et al. Update of the National Surgical Adjuvant Breast and Bowel Project Study of Tamoxifen and Raloxifene (STAR) P–2 Trial: preventing breast cancer. Cancer Prevention Research 2010; 3(6):696–706.

    [PubMed Abstract]

14. Goss PE, Ingle JN, Alés-Martinez JE, et al. Exemestane for breast-cancer prevention in postmenopausal women. New England Journal of Medicine 2011; 364(25):2381–2391.

    [PubMed Abstract]

15. Fisher B, Costantino JP, Wickerham DL, et al. Tamoxifen for prevention of breast cancer: report of the National Surgical Adjuvant Breast and Bowel Project P–1 Study. Journal of the National Cancer Institute 1998; 90(18):1371–1388.

    [PubMed Abstract]

16. Gorin MB, Day R, Costantino JP, et al. Long-term tamoxifen citrate use and potential ocular toxicity. American Journal of Ophthalmology 1998; 125(4):493–501.

    [PubMed Abstract]

17. Tamoxifen for early breast cancer: an overview of the randomised trials. Early Breast Cancer Trialists’ Collaborative Group. Lancet 1998; 351(9114):1451–1467.

    [PubMed Abstract]

18. Amir E, Seruga B, Niraula S, Carlsson L, Ocaña A. Toxicity of adjuvant endocrine therapy in postmenopausal breast cancer patients: a systematic review and meta-analysis. Journal of the National Cancer Institute 2011; 103(17):1299–1309.

    [PubMed Abstract]

19. Coates AS, Keshaviah A, Thürlimann B, et al. Five years of letrozole compared with tamoxifen as initial adjuvant therapy for postmenopausal women with endocrine-responsive early breast cancer: update of study BIG 1–98. Journal of Clinical Oncology 2007; 25(5):486–492.

    [PubMed Abstract]

20. Arimidex, Tamoxifen, Alone or in Combination (ATAC) Trialists’ Group. Effect of anastrozole and tamoxifen as adjuvant treatment for early-stage breast cancer: 100-month analysis of the ATAC trial. Lancet Oncology 2008; 9(1):45–53.

    [PubMed Abstract]

21. Coombes RC, Kilburn LS, Snowdon CF, et al. Survival and safety of exemestane versus tamoxifen after 2–3 years’ tamoxifen treatment (Intergroup Exemestane Study): a randomised controlled trial. Lancet 2007; 369(9561):559–570. Erratum in: Lancet 2007; 369(9565):906.

    [PubMed Abstract]

22. Boccardo F, Rubagotti A, Guglielmini P, et al. Switching to anastrozole versus continued tamoxifen treatment of early breast cancer. Updated results of the Italian Tamoxifen Anastrozole (ITA) Trial. Annals of Oncology 2006; 17(Suppl 7):vii10–vii14.

    [PubMed Abstract]

23. Osborne CK, Pippen J, Jones SE, et al. Double-blind, randomized trial comparing the efficacy and tolerability of fulvestrant versus anastrozole in postmenopausal women with advanced breast cancer progressing on prior endocrine therapy: results of a North American trial. Journal of Clinical Oncology 2002; 20(16):3386–3395.

    [PubMed Abstract]

Related Resources

• Adjuvant and Neoadjuvant Therapy for Breast Cancer
• Understanding Cancer Series: Estrogen Receptors/SERMs
• What You Need To Know About™ Breast Cancer
• Breast Cancer Home Page
• Breast Cancer Prevention (PDQ®)
• Breast Cancer Treatment (PDQ®)
• Agency for Healthcare Research and Quality, Reducing the Risk of Breast Cancer With Medicine: A Guide for Women

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What Is General Surgery

If you are interested in  training in the area " General Surgery" it is the study of surgery that has many applications.  It generally will take at least 5 years to go thru all the programs. There is about 12 months that will be cover a single surgical area. Six months or less of schooling will be covering nonsurgical clinical areas which covers internal medicine, pediatrics, gastroenterology, anesthesiology, or surgical pathology. There will be about 54 months of clinical surgery which covers endoscopy, surgical intensive care, and emergency care.  There will also be three years that cover general surgery.

A general surgeon  gets trained in the basics of all surgical specialties. They will learn about anatomy, physiology, metabolism, immunology, nutrition, patholgy, wound healing, shock, resuscitation, intensive care, and neoplasia. A general surgeon also must learn to be able to diagnosis, learn the basics of preoperative, oberative, and postoperative management.

A general surgeon must learn how to deal with any complications that arise from surgery. The study of general surgery is going to cover nine components of surgery which include: the Alimnentary tract, Abdomen and it's contents, breast, skin, and soft tissue, head and neck including trauma, vascular, endocrine, congentital and oncologic disorders-primarily skin tumors, salivary glands, thyroid, parathyroid, and oral cavity., They would learn all about the vasular system which excludes the intracranial vessels and heart

A general surgeon also studies surgical oncology which includes screening, surveillance, surgical adjunctive therapy, rehabilitation, and follow-up of cancer patients. In "General Surgery" you will need to have a comprehensive management of trama of musculoskeletal, hand and head injuries. A general surgeon is responsible for care of an injured patient. They will need to provide complete care of critically ill patients in the emergency room, icu, and trama/burn units. You can go learn more information from the American board of Surgery.

Girl's Life Saved by Spinal Surgery

A 12-year-old girl suffering from an extremely severe case of scoliosis received another chance at life after undergoing drastic surgery at a hospital in Indianapolis. Salma Suleman, a resident of Nairobi, Kenya was unable to walk any distances greater than 10 feet due to the extreme curve of her spine.

A foundation in San Diego, CA known as the Nuvasive Spine Foundation was able to bring Suleman to the United States. The Peyton Manning Children's Hospital in St. Vincent even volunteered to perform the extremely risky surgery pro bono.

She was suffering from a curve so severe that if you looked from behind, her hip and shoulder blade were actually touching. This doctors stated that her case of scoliosis was the most severe they had ever seen in all their 17 years working as a spinal surgeons.

"We typically operate on children if their curves are 45 to 50 degrees. If their curves are 25 to 30 degrees we put them in braces. She is only 12 and she was already suffering from a 170 degree curve," said Schwartz.

Schwartz was the surgeon who performed the almost 12-hour surgery. Suleman received 15 different levels of fusion during the surgery.

Just three short weeks after the surgery she is able to stand up straight, raise her arms and even walk without pain. The surgery has completely changed her outlook on life.

"I am happy," said Suleman. "I had lost hope but he brought it back."

Suleman will spend approximately one month undergoing rehab in San Diego and will then head home to Nairobi.

A Patient's Own Stem Cells Can Initiate Heart Healing

According to a report published Monday, researchers say that the cells from a patient's own heart can be utilized to regrow new tissue in one's own heart, as well as reverse damage caused by a heart attack.

Scientists from both John Hopkins University in Baltimore and Cedars-Sinai Medical Center in Los Angeles used cells grown from 17 patients to reverse the damage inflicted by their heart attacks. The researchers say that these safe procedures prove that a person's own cells can initiate new heart muscle growth as well as reduce scarring.

When someone experiences a heart attack, that person's heart is left with massive scarring. This scarred heart muscle tissue cannot pump blood as quickly as it did before. Furthermore, other parts of the heart must now help to circulate blood throughout the body, and this process places stress on these other parts of the heart that assist with this process. Since the damaged heart area can't properly conduct electrical currents, abnormal heart rhythms develop, which could potentially cause more heart problems, including heart failure.

Dr. Eduardo Marban, director of the Cedars-Sinai Heart Institute says that this process is the first example of therapeutic regeneration. Marban adds that many spontaneous regenerations of tissues and limbs abound in nature, such as a damaged human liver regrowing to its former full size, or a salamander growing a new tail after it has been severed. He goes on to explain that doctors have not previously been able to initiate therapeutic regeneration in heart patients, but that this could change soon if prolonged patient outcomes – and large-scale clinical trials – validate the results published Monday in the medical journal, The Lancet.

Marban, along with his colleagues, initially presented these findings in November at an American Heart Association conference.

Dr. Peter Johnson, one of the study's authors, said that to gain admittance into this clinical trial, recent heart attack sufferers had to have experienced a considerable amount of damage to their hearts. He also said that participants had to experience lessened squeezing of [blood into the body].

Twenty-five patients participated in this clinical trial held to ascertain the safety of growing cells from one's heart to be injected back into one's heart. Only 17 of these patients actually received the cell transplants, while the remaining eight patients underwent standard post-heart attack treatments.

In this outpatient study, the doctors overseeing the procedure inserted a catheter into each patient's heart, and took out peppercorn-sized pieces of tissue from the healthy portions of the patient's heart. Then, utilizing a procedure invented by Marban, the researchers isolated heart stem cells from the rest of the extracted tissue, and grew millions of new heart cells in a petri dish.

Roughly four to six weeks after the patients experienced the heart attacks, each one had from 12 to 25 million of their own cells derived from their hearts injected back into their hearts.

Marban says that when the initial, first patient's results came back, he and his colleagues were pleased to document that the procedure was safe. After one year, Marban's team reported that just one patient experienced a life-threatening side effect that might have been brought on by the experimental cell transfer.

Six months after the first patient received the treatment derived from the tissue in his own heart, new tissue had regenerated, and the patient experienced significant shrinking of his scar tissue, says Marban, who adds that this is an unprecedented event.

The researchers followed all of the patients for six months, and then continued to monitor 21 of the patients for one year. Half of the patients studied experienced a 50 percent decrease in their scar tissue, and an overall reduction in scar size, says Marban. However, Marban admits that he does not know why these findings occurred.

The amount of new heart tissue grown in the study participants was not small, says Marban, who cites an average of 78 ounces of new heart tissue found in each patient. He says these findings are quite extraordinary, since the section of the heart that pumps bloods is about 5.3 ounces.

Patients in the study that did not receive the heart cell transplants did not experience new tissue growth and their scarring remained exactly the same.

The deputy director of the NIH's National Heart, Lung, and Blood Institute's Division of Cardiovascular Sciences, Sonia Skarlatos, Ph.D., says this preliminary research is an exciting move forward. However, she says that much more research of this type needs to be performed on a lot more patients who should be monitored for longer periods than reported in the first study. She does admit that she is hopeful that the follow-up study's reports will confirm this first study's positive results.

Skarlatos says that through the prevention of heart attacks, you might prevent heart failure that occurs in many of these post-heart attack patients. She did not participate in the research, yet the National Heart, Lung and Blood Institute did fund the study.

Skarlatos adds that it is still unclear why the scar tissue disappeared and the heart tissue regenerated. Did the cells, the cell proteins or another factor contribute to these occurrences? Only further research will tell, she says.

We did witness a flash of hope during animal testing of this nature. However, human testing yielded much better results, says Marban, who adds that it usually does not transpire this way in medical research.

UIC Surgeons Perform Robotic Gallbladder Removal Via A Single Port

Robotic surgery to remove a gallbladder via a single port was performed for the first time in the Midwest recently by surgeons at the University of Illinois at Chicago.

Gallbladder surgery (a cholecystectomy) using this method involves a single incision instead of multiple cuts and less scarring, according to Dr. Enrico Benedetti, head of the department of surgery at UIC.

In robotic surgery, the surgeon sits at a console operating joysticks that control the robot while its arms perform the actual surgery. The doctor sees the patient and every step of the procedure on various screens and can intervene immediately if necessary.

Dr. Pier Giulianotti, the surgeon at UIC who performed the robotic gallbladder removal, first began practicing robotic surgeries in 1999 and has since done hundreds of them.

The robotic surgeries are done at the University of Illinois Health & Sciences System, the renamed medical center at 1740 W. Taylor St.

“From the beginning I understood that the future of medicine would be connected to computers and robots,” Giulianotti said.

Gallbladder removal “is a very common procedure, performed half a million times in the United States a year,” Benedetti said.

Many of those patients are women for whom a procedure that reduces scarring is important.

Gallbladder removal used to involve conventional, open cavity surgery and then, in the late 1980s, the procedure started to be performed with laparoscopy, according to Dr. Benedetti. Laparoscopy involves inserting a camera into small incisions and then inflating the area with carbon dioxide to get a better view and perform the removal.

Gallbladder removal can be a recommended form of treatment for many gallbladder problems, according to the National Institutes of Health. The gallbladder stores bile from the liver.

A multi-port laparoscopy was the initial method used, but the focus has been on performing the operation with only a single port to reduce scarring. This can prove problematic when using laparoscopy, since all of the instruments are entering through a single port in the belly button in a straight alignment. Performing the operation with the robot can give the surgeon a better view of what he or she is doing.

Dr. Sherry Wren, professor of surgery at Stanford University, said that the single port surgery allows patients to avoid the three extra incisions and the robotic version of the single port surgery is better because of “the better viewpoint, ability to do better retraction, the ability to have a camera that isn’t colliding with your other instruments. It really reestablishes the ability to work in the safest manner on the gallbladder.”

Wren is a consultant for Intuitive Surgical, the California company that makes the robot (the da Vinci surgical system) used in the gallbladder removal. The robot is also used for surgical procedures involving various kinds of cancer, obesity, kidney disorders and uterine fibroids.

Benedetti pointed to the increased visibility robotic surgery provides for the surgeon as well as the fact that the robot filters out human hand tremors.

Criticism of the robot has centered on the price and practicality of having it at a hospital. Benedetti mentioned that Intuitive Surgical is the only company currently making the surgical robots. As competitors arise, the cost could potentially go down. Additionally, as the people becoming doctors are increasingly tech-savvy individuals, robotic surgery could itself become part of medical school training.

Dr. Marie Crandall, associate professor of surgery at the Northwestern University Feinberg School of Medicine, said that one area the robot still can’t be used is in trauma surgeries and that it would not be a good choice “when you need quick access to the abdomen for things like bleeding or intestinal spillage”

“I think it has the potential to be very helpful in minimally invasive applications where you need tremendous control over your instruments,” Crandall said.

Giulianotti called planning for the operating room of the future his “obsession” and mentioned improved patient comfort and understanding, converting to wireless, a central role for computers and robots and having a constant interface with surgeons in other locations as important.

He went on to say he thought surgery today was at the end of a 19th century process and that it was time to start at ground zero to reimagine the operating room.

Asked whether we’d ever see a completely automated surgery, he said, “I think the difference between the human mind and a computer is that the human mind can make errors. You can learn more and you can achieve also another step of knowledge. If you’re always repeating what you think is true, you’ll always stay at the same level.”

But until artificial intelligence can mimic the kinds of fortunate mistakes that lead to new discoveries, humans will still be needed for the surgical process, he said.

Exam Your Medicine Cabinet Before It Kills You

Have you checked your medications lately? Are any medications safe to use after their expiration date or in combination with other medications? What should you do with your old outdated medications? These simple questions can start you on the path to protecting you and your family.

The AMA is offering a guide to assist in safely disposing of your medications. This guide will show you how to dispose of medications safely by keeping them out of local water and protect your children or adults from accidentally ingesting or misusing them.

"Many patients use prescription and over-the-counter medications as part of their health care routine, but if not properly disposed of these otherwise beneficial drugs can be extremely harmful," said AMA President Peter W. Carmel, M.D. "It is easy to accumulate expired or unneeded medications in a medicine cabinet, and Patient Safety Awareness Week provides an excellent opportunity to learn about the best way to get rid of these potential hazards."

The AMA also offers you tools to assist you with keeping records of all your medications and you can contact their physicians to answer your questions. Their medication safety checklist will assist you with keeping records of not only prescription medications but vitamins, your herbal, home remedies and alternative methods you may have read about. With all this information conveniently accumulated you can then supply them to your doctor. The AMA's MyMedications app, available on iTunes, will easily provide a place to file information on your medications, allergies and immunization records which can then be emailed to physicians and family.

"Patients with multiple conditions may see more than one prescribing physician and use other non-prescription medicines, so it is critically important to make sure these treatments are safe together," said Dr. Carmel. "The AMA encourages patients to discuss with their physicians all vitamins and medications, including prescription and over-the-counter, that they are currently taking. The medication safety checklist and MyMedications app provide great ways to start this important discussion and safely manage your medications."

Exam Your Medicine Cabinet Before It Kills You

Have you checked your medications lately? Are any medications safe to use after their expiration date or in combination with other medications? What should you do with your old outdated medications? These simple questions can start you on the path to protecting you and your family.

The AMA is offering a guide to assist in safely disposing of your medications. This guide will show you how to dispose of medications safely by keeping them out of local water and protect your children or adults from accidentally ingesting or misusing them.

"Many patients use prescription and over-the-counter medications as part of their health care routine, but if not properly disposed of these otherwise beneficial drugs can be extremely harmful," said AMA President Peter W. Carmel, M.D. "It is easy to accumulate expired or unneeded medications in a medicine cabinet, and Patient Safety Awareness Week provides an excellent opportunity to learn about the best way to get rid of these potential hazards."

The AMA also offers you tools to assist you with keeping records of all your medications and you can contact their physicians to answer your questions. Their medication safety checklist will assist you with keeping records of not only prescription medications but vitamins, your herbal, home remedies and alternative methods you may have read about. With all this information conveniently accumulated you can then supply them to your doctor. The AMA's MyMedications app, available on iTunes, will easily provide a place to file information on your medications, allergies and immunization records which can then be emailed to physicians and family.

"Patients with multiple conditions may see more than one prescribing physician and use other non-prescription medicines, so it is critically important to make sure these treatments are safe together," said Dr. Carmel. "The AMA encourages patients to discuss with their physicians all vitamins and medications, including prescription and over-the-counter, that they are currently taking. The medication safety checklist and MyMedications app provide great ways to start this important discussion and safely manage your medications."

CMS Wants To Deny Prescription Coverage

CMS or the (Centers for medicare and Medicaid) want to stop prescription drug abuse but the method they have chosen to do so may hurt patients who really need the medicine. Their proposal would allow medicare to deny Medicare Part D medication coverage to people they suspect of prescription abuse.

The AMA is worried that this is going to cause problems for people who are really in need of medical treatment. "Physicians, not health insurers, have the expertise to make decisions about which medications a patient should receive," AMA President Peter W. Carmel, MD, said in a news release. "Medicare patients who are seriously ill or in severe pain should not be unjustly denied the medications prescribed by their physician." The AMA agrees that misusing prescriptions is a serious problem but that CMS is not qualified to make the decision if someone is abusing their prescriptions or not.

The AMA offers a solution that drug plans provide claim information to physicians. They believe in a real-time prescription information for doctors and increased funds for drug-monitoring programs.

Stop Plans To Weaken Prescription Drug Access For Medicare Patients

Provisions that allow Medicare drug plans to deny drug coverage to patients when they suspect prescription misuse was being proposed by the Centers for Medicare and Medicaid Services (CMS). However, the American Medical Association (AMA) were against the proposed policy. The AMA stated its concerns that the policy would instead prevent patients from receiving Medicare Part D coverage for medications prescribed to them by their physician. The AMA were strongly against this idea and making their statement that "Physicians, not health insurers, have the expertise to make decisions about which medications a patient should receive."

Suggestions from the AMA include encouraging health insurers to fully share information so that prescribing physicians will know all of a patients' medications, increasing the funding for prescription drug monitoring programs, as well as for upgrades that provide real time prescription information to physicians at the point of care.

The AMA held strong in their beliefs that giving health insurers the ability to stop insuring medications prescribed by a physician is not the answer in dealing with the misuse of prescription drugs.

Stop Plans To Weaken Prescription Drug Access For Medicare Patients

Provisions that allow Medicare drug plans to deny drug coverage to patients when they suspect prescription misuse was being proposed by the Centers for Medicare and Medicaid Services (CMS). However, the American Medical Association (AMA) were against the proposed policy. The AMA stated its concerns that the policy would instead prevent patients from receiving Medicare Part D coverage for medications prescribed to them by their physician. The AMA were strongly against this idea and making their statement that "Physicians, not health insurers, have the expertise to make decisions about which medications a patient should receive."

Suggestions from the AMA include encouraging health insurers to fully share information so that prescribing physicians will know all of a patients' medications, increasing the funding for prescription drug monitoring programs, as well as for upgrades that provide real time prescription information to physicians at the point of care.

The AMA held strong in their beliefs that giving health insurers the ability to stop insuring medications prescribed by a physician is not the answer in dealing with the misuse of prescription drugs.