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Breast Cancer Treatment

Surgery to remove cancerous tissue is the primary treatment for breast cancer. Surgery is often supplemented by additional therapies or a combination of therapies, such radiation therapy, chemotherapy, hormone therapy, targeted therapy, and bisphosphonates. Pain management and supportive care are also an important part of a person's breast cancer treatment.

The additional therapies are either given before or after the surgery:

  • Neoadjuvant therapy
    Neoadjuvant therapy (preoperative treatment) is used before surgery to shrink the tumor and make it easier to remove surgically.
  • Adjuvant therapy
    Adjuvant therapy (postoperative treatment) is used after surgery to reduce the chance of the breast cancer recurring or to destroy any cancer cells that have spread (metastasized) to other parts of the body.

Different surgical procedures and therapies are available for each type and stage of breast cancer. A doctor creates a person's breast cancer treatment plan based on the cancer's:

  • Type and stage
  • Hormone sensitivity
  • Production of the HER2 gene and HER2 protein

The treatment plan also depends on a person's overall health and personal preferences. People should discuss the advantages and disadvantages of each treatment option with their doctor. Helpful information can also be provided by breast cancer organizations and support groups.

Some people decide to get a second opinion about their breast cancer diagnosis and treatment plan, and many insurance companies cover the second opinion. Gathering medical records and scheduling an appointment with another doctor can be time consuming. People who need to start treatment as soon as possible should discuss the advisability of this delay with their doctor.

Breast cancer treatments include:

A doctor should be notified if any severe reactions occur during treatment. People should also ask their doctor or pharmacist in advance for possible drug side effects or interactions. The following list of medications isn't inclusive. Additional information, side effects, and drug interactions can be obtained by clicking the name of the highlighted medications.

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Surgery

Surgery is the standard treatment for breast cancer and several surgical procedures are available. The goal of each type of surgery is to remove all of the cancerous tissue while sparing as much healthy tissue as possible. Additional therapies (such as radiation or chemotherapy) may be used to prevent the breast cancer from returning or spreading.

Common breast cancer surgical procedures include:

Lumpectomy

A lumpectomy is a breast-conserving surgery that only removes the cancerous lump and some of the surrounding normal tissue. A sentinel node biopsy may be used to remove and test some of the underarm lymph nodes to determine whether the cancer cells have spread.

After a lumpectomy, most people receive radiation therapy to destroy any remaining cancer cells in the breast. If chemotherapy is needed, the radiation therapy is usually delayed until after the completion of the chemotherapy.

Mastectomy

A mastectomy removes part or all of the breast tissue, and may also remove some or all of the lymph nodes under the arm and muscle under the breast. A mastectomy may be followed by an adjuvant therapy (such as radiation treatment or chemotherapy) or a combination of therapies.

There are four types of mastectomy:

  • Partial mastectomy
    A partial mastectomy is a breast-sparing surgical procedure that only removes the cancerous breast tumor and some of the surrounding.
  • Simple or total mastectomy
    A simple mastectomy removes the entire breast. Both breasts may be removed for women who have a very high risk of breast cancer. The procedure has few side effects and only requires a short hospital stay.
  • Modified radical mastectomy
    A modified radical mastectomy removes the entire breast and some of the lymph nodes in the adjacent armpit (axilla). Lymph node procedures include:
    • Sentinel lymph node biopsy
      A sentinel lymph node biopsy removes fewer lymph nodes and causes fewer side effects.
    • Axillary lymph node dissection
      If cancer is discovered in any of the sentinel lymph nodes, axillary lymph node dissection removes the remaining lymph nodes in the adjacent armpit. The procedure may cause lymphedema (swelling of the arm and hand) or nerve damage
  • Skin-sparing mastectomy
    A skin-sparing mastectomy is designed to cause less disfiguration. The procedure removes the cancerous breast tissue through an incision around the nipple. Skin-sparing mastectomy has been shown to be as effective as a modified radical mastectomy.
  • Radical mastectomy
    A radical mastectomy removes the entire breast, the lymph nodes in the adjacent armpit, and the chest muscles under the breast. The surgery is rarely performed today, because a modified radical mastectomy has been shown to be as effective, has fewer side effects, and is less disfiguring.

Preventative (prophylactic) mastectomy

In rare cases a mastectomy is used to prevent breast cancer. A prophylactic mastectomy is designed to reduce the risk of breast cancer by surgically removing both breasts before breast cancer is diagnosed. The American Cancer Society (ACS) Board of Directors has stated that prophylactic mastectomy should only be considered by women with one or more of the following risk factors:

  • A mutated BRCA genes found by genetic testing
  • Previous cancer in one breast
  • Breast cancer in several close relatives
  • Biopsy specimens showing lobular carcinoma in situ

Other preventative choices include:

  • Taking tamoxifen
  • Maintaining a healthy lifestyle, which includes:
    • Exercising regularly
    • Limiting alcohol
    • Maintaining a healthy weight
    • Not smoking
    • Not taking supplemental estrogen

Breast surgery recovery

Breast surgery recovery varies among people and depends on the type of surgery performed. A healthcare provider can recommend exercises to help reduce pain and stiffness, and improve movement and strength.

Pain medication helps reduce post-surgical pain and can be adjusted as needed. A healthcare provider should be notified if any of the following problems develop during recovery:

  • Infection or bleeding
  • Skin tightness
  • Muscle weakness or stiffness

Tingling and numbness sometimes develop due to cut nerves. The tingling and numbness usually disappear after a few weeks or months, although in some cases the numbness may not totally disappear.

Lymphedema

Lymph node removal may cause lymphedema, which is a swelling of the arm and hand on the same side as the surgery. It's important to protect the arm and hand on the treated side from injuries, such as cuts, bruises, insect bites, and sunburn. A healthcare provider should be notified if the arm or hand gets injured, or becomes swollen, red, or warm.

Lymphedema treatments include:

  • Avoiding limb constriction
  • Elastic sleeve on the arm
  • Elevating the arm above the heart whenever possible
  • Hand and arm exercises
  • Manual lymph drainage (massage)
  • Medication
  • Pneumatic compression (a machine that gently compresses the arm)

Breast reconstruction

Many women decide to have breast reconstruction after a mastectomy to restore the appearance of their breast. The reconstructive surgery is either performed at the time of the mastectomy or afterwards. Women are advised to discuss their breast reconstruction options with the surgeon or plastic surgeon before their mastectomy is performed. There are two types of breast reconstruction:

  • Breast reconstruction with implants
    Reconstruction with implants replaces breast tissue with an implant made of silicone gel or saline. A tissue expander may be used for women without sufficient skin and muscle to cover the implant. An empty implant shell is placed under the skin and muscle, and gradually filled with fluid over a period of several months. After the skin and muscle have stretched sufficiently, the expander is replaced with a permanent implant.
  • Breast reconstruction with a tissue flap
    Reconstruction with a tissue flap rebuilds the breast using tissue, fat, and muscle from a person's abdomen, back, or buttocks. The procedure involves a longer recovery time and a higher risk of infection. It also may not be suitable for people with little body fat. Some people choose to have additional surgery to create a nipple and areola (the pigmented area around the nipple).

Breast prostheses

Breast prostheses are breast forms that are worn to cosmetically duplicate the natural shape of a woman's breast or part of a woman's breast. Prostheses are used as an alternative to breast reconstructive surgery or until a woman is ready for reconstructive breast surgery. Various designs and materials are available.

Silicon breast prostheses are the most popular. Prostheses made of softer materials can be worn until a woman's surgical wound heals. Non-silicon prostheses are also used during radiation therapy, which often makes the breast skin too sensitive to wear silicon prostheses.

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Radiation therapy

Radiation therapy uses high-powered X-rays (external radiation) or radioactive seeds (internal radiation) to kill any breast cancer cells that remain after surgery. Radiation therapy is given after a lumpectomy and sometimes after a mastectomy. It is sometimes used before surgery to shrink large, difficult to remove tumors.

Two types of radiation therapy are available:

  • External radiation
    External radiation uses a large X-ray machine in a hospital or clinic. The treatment is repeated five days a week for several weeks.
  • Internal radiation
    Internal radiation (brachytherapy) implants radioactive seeds (pellets) in the breast tissue next to the cancerous tissue. Some people remain in the hospital until the implants are removed.

Radiation therapy side effects include:

  • Breast swelling and heaviness
  • Fatigue
  • Irritated skin at the site

Most side effects gradually go away after treatment. Because radiation therapy can harm a fetus, it is not given to pregnant women.

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Chemotherapy

Chemotherapy (chemo) uses a combination of different types of cancer-killing drugs to destroy all breast cancer cells in the body. Chemotherapy treats the whole body, which makes it especially helpful when breast cancer has spread beyond the breast and underarm area. It is often used in combination with surgery and/or radiation therapy.

Chemotherapy is either given at a hospital, doctor's office, or at home. Chemotherapy drugs are typically given orally or by injection. The bloodstream helps distribute the drugs to cancer cells that have spread to distant organs (metastasized). The actions of the drugs and side effects experienced depend on the type of drugs used, the amounts given, and the length of the treatment.

Chemotherapy is usually given in cycles of treatment from a few days to a few weeks, followed by a week or two of recovery before the next cycle begins. People are tested regularly to determine how well they are tolerating the treatment. The treatment may be temporarily delayed to give people additional time to recover. After several treatment cycles, diagnostic tests are given to determine the effect of chemotherapy on the cancer. The entire course of treatment may last up to six months. Because chemotherapy can harm a fetus, it is not given to pregnant women.

Chemotherapy drug classifications

The different types of chemotherapy drugs are grouped into classifications, based on how they work. Chemotherapy drug classifications include:

  • Alkylating agents
    Alkylating agents damage DNA (deoxyribonucleic acid, the genetic material of the genes), which prevents cells from reproducing.
    Example: cyclophosphamide (Cytoxan)
  • Antimetabolites
    Antimetabolites interfere with DNA and RNA (ribonucleic acid) growth.
    Example: fluorouracil (Fluorouracil, 5-FU, Adrucil)
  • Antitumor antibiotics
    Antitumor antibiotics interfere with the enzymes involved in DNA production.
    Examples: doxorubicin (Adriamycin) and bleomycin (Blenoxane)
  • Antimitotic agents
    Antimitotic agents are plant alkaloids and other compounds derived from natural products that prevent cells from dividing normally.
    Examples: paclitaxel (Taxol), docetaxel (Taxotere)
  • Hormones
    Hormones slow the growth of some cancers that depend on the hormones.
    Example: tamoxifen (Nolvadex, tamoxifen citrate)

Chemotherapy drug combinations

Chemotherapy drugs may be given individually or in combinations. Chemotherapy drug combinations for breast cancer include:

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Hormone therapy

Some breast tumors need hormones to grow. Estrogen-receptor positive (ER-positive) tumors grow when high levels of estrogen are present in the body. Hormone therapy kills ER-positive tumors by preventing the breast cancer cells from getting or using the natural hormones they need to grow.

Selective estrogen receptor modulators

Selective estrogen receptor modulators (SERMs) prevent the growth of ER-positive tumors by blocking the effect of estrogen on these tumors. The most commonly prescribed SERM is:

Tamoxifen is used to treat:

  • Breast cancer that has spread (metastasized)
  • Women who have a high risk of breast cancer
  • Ductal carcinoma in situ after surgery

Tamoxifen can be used by both pre- and postmenopausal women. Some women who are still menstruating experience menopausal symptoms while taking tamoxifen. Tamoxifen can harm the fetus and is not given to pregnant women.

Serious side effects of tamoxifen are rare, and more likely to occur in older women with other medical conditions. These side effects include cancer of the uterus, stroke, and blood clots in the lung. Women taking tamoxifen are advised to have regular pelvic exams, and should notify their doctor immediately if they develop any unusual vaginal bleeding, trouble breathing, one-sided weakness, or vision or speech problems.

Aromatase inhibitors

Aromatase inhibitors block the growth of ER-positive tumors by stopping estrogen production in cells other than the ovaries (such as fat cells and the adrenal gland). Aromatase inhibitors are prescribed to prevent breast cancer from recurring or spreading (metastasizing). They are often given after tamoxifen therapy or when tamoxifen therapy doesn't work. Examples include:

Because aromatase inhibitors don't stop estrogen production in the ovaries, they are only prescribed to women with ER-positive breast cancer who are postmenopausal. Some women with ER-positive breast cancer who have not gone through menopause are prescribed aromatase inhibitors after surgery to remove their ovaries.

Aromatase inhibitors may cause or worsen osteoporosis. Women are advised to have a bone density test before starting treatment. Although supportive care treatments to prevent bone loss may be sufficient to protect women with normal bone density from bone loss, aromatase inhibitors may not be appropriate for women who already have osteoporosis.

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Targeted therapy

Targeted therapy (biological therapy) uses monoclonal antibody technology to target the gene changes that cause cancer. Monoclonal antibodies are man-made versions of immune system proteins produced by the body to fight disease. Targeted therapy is often used with chemotherapy drugs. Examples include:

  • trastuzumab (Herceptin)
    Herceptin kills HER2-positive breast cancer by blocking the HER2 protein, which HER2-positive breast cancer cells need to grow and spread. Herceptin is given intravenously (IV). It is either given alone, or with chemotherapy or hormone therapy. Herceptin is used for metastatic or advanced breast cancer. In October 2007, the Food and Drug Administration (FDA) approved Herceptin (trastuzumab) treatment after a lumpectomy for early stage breast cancer that has not spread beyond the breast or lymph nodes. The treatment is limited to women who do not have heart failure or cardiomyopathy (weak heart muscle). Herceptin side effects are mild and typically stop after the initial treatment. The more serious side effects include heart damage and lung problems, which usually improve after treatment. People taking Herceptin should have their heart and lungs examined before and during treatment, and should notify their doctor if they experience any shortness of breath, swelling, or problems engaging in physical activity.
  • lapatinib (Tykerb)
    Tykerb is prescribed for people with HER2-positive breast cancer when Herceptin has stops working. Tykerb works with chemotherapy in people with metastatic or advanced breast cancer. Tykerb is prescribed as a pill. Tykerb can cause upset stomach, and discomfort of the hands and feet. In rare cases it may cause heart problems, which go away after treatment. People should notify their doctor if they experience shortness of breath.

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Bisphosphonates

Bisphosphonates prevent bone damage when breast cancer cells spread to the bones. Bisphosphonates work by lowering calcium levels in the blood and slowing down bone loss. The drugs are given intravenously (IV). Examples include:

Some women taking bisphosphonates develop jaw bone deterioration. Dental work should be performed before starting bisphosphonate treatment.

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Treatment side effects

Although many of the breast cancer treatments have side effects, most of the side effects go away after the treatment stops. Breast cancer treatment side effects include:

  • Anemia (lower than normal number of red blood cells)
  • Bruising or bleeding after injury
  • Constipation
  • Fatigue
  • Hair loss
  • Increased risk of infection
  • Loss of appetite
  • Nausea and vomiting
  • Mouth sores
  • Premature menopause
  • Hot flashes

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Pain management

Breast cancer treatment includes pain management. The best way to control pain and prevent it from getting worse is to treat the pain early. Cancer pain medications rarely become addictive when taken as prescribed by the doctor. The doctor gradually lowers the dose so a person's body has time to adjust when the pain treatment stops.

Some pain medications may cause side effects, such as nausea and vomiting, constipation, or drowsiness. These side effects often stop after a few days. People should report any problem side effects to a doctor, who can help them manage these symptoms. People usually cannot take aspirin, ibuprofen, and other NSAIDs during chemotherapy.

Pain medications are given:

  • Orally (in pill or capsule form)
  • Subcutaneously (injection)
  • Intravenously (into a vein)

Mild-to-moderate persistant pain: non-opiods

An opiod is drug that has sedative or narcotic effects similar to opium. Mild-to-moderate pain that is persistent can usually be treated with non-opiod medications, such as:

Analgesics

Analgesics relieve pain. The following over-the-counter (nonprescription) analgesic helps treat mild pain:

Nonsteroidal anti-inflammatory drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) relieve pain and inflammation. Over-the-counter NSAIDs include:

Prescription NSAIDs include:

Moderate-to-severe persistant pain: opiods

Opiods are prescription narcotics that provide the main relief for more severe pain. They are available in both long-acting forms to help people sleep through the night and short-acting forms for quick relief. Many people continue to take regular doses of aspirin, acetaminophen, or ibuprofen while taking opiods. Some pain medications combine an opioid and a non-opioid in the same pill.

Long-acting opioids include:

Short-acting opioids used for breakthrough pain and include:

Coanalgesics

Coanalgesics have analgesic effects although they are primarily used for conditions other than pain relief:

Tricyclic antidepressants

The following tricyclic antidepressants help relieve some types of pain:

SSNRI antidepressants

The following selective serotonin and norepinephrine reuptake inhibitor (SSNRI) antidepressants help relieve some types of pain:

Anticonvulsant drugs

The following anticonvulsant (antiseizure) drugs are prescription medications that help control burning or tingling pain:

Cortocosteroids

The following cortocosteroids are prescription medications that help relieve pain caused by swelling:

Antihistamines

Antihistamines are primarily used to relieve allergy symptoms. The following antihistamine helps control nausea, vomiting, and dizziness that results from cancer treatment:

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Supportive care

Supportive care (palliative care) doesn't cure breast cancer. Instead, it improves the quality of life for people with breast cancer. Breast cancer supportive care helps treat symptoms, treatment side effects, and any related emotional problems.

Advanced breast cancer symptoms include discomfort, pain, and swelling. Breast cancer treatment side effects include:

  • Anemia (lower than normal number of red blood cells)
  • Bone loss
  • Bruising or bleeding after injury
  • Constipation
  • Diarrhea
  • Fatigue
  • Hair loss
  • Increased risk of infection
  • Loss of appetite
  • Nausea and vomiting
  • Mouth sores
  • Premature menopause

Although most symptoms and side effects go away after the treatment stops, the following supportive care therapies help people during treatment:

Treating anemia

Chemotherapy drugs often reduce red blood counts, causing people to become anemic and feel less energetic. The following medications help the body increase red blood cells during chemotherapy:

Treating bone loss

People can slow down bone loss caused by their breast cancer treatment by:

  • Adding calcium and vitamin D to their diet
  • Performing weight-bearing exercises

Medications that help reduce bone lose include:

Treating constipation

Dietary changes that help avoid constipation caused by breast cancer treatments include:

  • Drink plenty of liquids.
  • Eat foods high in fiber or roughage (uncooked fruits, vegetables, and whole grain breads and cereals).
  • Exercise as much as possible.

People who experience constipation should contact their doctor to determine if it's appropriate for them to take a laxative or stool softener, or use an enema.

Treating diarrhea

Dietary changes that help relieve diarrhea include:

  • Initially drink clear liquids.
  • Gradually start eating small meals of low-fiber foods.
  • Avoid food irritants (dairy, spicy or fatty foods, alcohol, or caffeine).

People who have diarrhea that lasts for more than 24 hours, or who experience pain and cramping should call their doctor for advice. Medications that help treat diarrhea include:

Treating emotional problems

Studies show that depression and anxiety can impact a cancer patient's quality of life even more than physical pain. People with breast cancer should be given sufficient time to express their feelings, concerns, hopes, and fears to their healthcare providers. Discussions with family and friends are also beneficial. Breast cancer support groups can provide coping suggestions, education, emotional support, social interaction, and help people with breast cancer avoid feelings of isolation.

Treating infection

Chemotherapy drugs can interfere with the body's ability to produce white blood cells to fight infection. Techniques to avoid infection during chemotherapy include:

  • Avoid children who have recently been vaccinated.
  • Avoid people with communicable diseases.
  • Don't share drinking glasses or eating utensils.
  • Don't share personal hygiene objects (combs, razors, toothbrushes, or washcloths).
  • Use lotion or cream if skin becomes too dry or cracked.
  • Wash hands with soap and water throughout the day, especially before eating and after bathroom use.
  • Wear protective gloves when gardening, handling or cleaning up after pets, or cleaning small children.

The following medication increases white blood cell counts during chemotherapy treatment:

Treating nausea and vomiting

People can prevent or relieve nausea and vomiting due to cancer treatments by:

  • Remaining in bed for an hour after taking medication.
  • Drinking clear liquids.
  • Eating small meals.
  • Avoiding foods that are sweet, fried, or fatty.
  • Avoiding unpleasant odors.

Antiemetic drugs (anti-nausea) help prevent or cure nausea and vomiting, which are common side effects of chemotherapy drugs.

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Lifestyle Changes

The following lifestyle changes are designed to help people lower their risk of developing breast cancer and its side effects.

Eating a healthy diet

Studies indicate a healthy diet can lower a person's risk of developing breast cancer. Dietary recommendations to prevent breast cancer from occurring or recurring include:

  • Eating at least 5 servings of fruits and vegetables a day.
  • Eating at least 3 servings of whole grains a day.
  • Limiting sugar and saturated fat.
  • Limiting alcohol consumption to one drink a day for women and two drinks a day for men.

Maintaining a healthy weight

Being overweight or obese appears to increase the risk of breast cancer.

  • People are advised to eat sufficient calories to maintain a healthy weight as determined by a healthcare provider.
  • Waist circumference and body mass index (BMI) are often used to determine a person's healthy weight.
    • A high-risk waistline is 35 inches or higher for women and 40 inches or higher for men.
    • To calculate BMI, multiply weight in pounds by 703, divide by height in inches, then divide again by height in inches.
    • Overweight is defined as a BMI of 25.0 to less than 30.0, obesity is defined as a BMI of 30.0 or greater, and extreme obesity is defined as a BMI of 40 or greater.
    • Note that although BMI is useful for most people, it is not precise for the elderly, pregnant women, or very muscular athlete.

Exercising

In addition to reducing a person's risk of breast cancer, exercise has been shown to limit breast cancer treatment side effects, such as fatigue. The American Cancer Society (ACS) recommends that people try to exercise for 45 to 60 minutes 5 or more days a week if possible.

Preventing memory problems

Techniques overcome memory problems include:

  • Correcting nutritional deficiencies
  • Engaging in attention-restoring activities (gardening, nature watching, walking)
  • Exercising regularly
  • Managing anxiety, stress, and depression
  • Treating sleep problems

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Complementary and Alternative Medicine

Complementary and alternative medicine refers to those medical and healthcare treatments that are not part of traditional medicine. Whereas, complementary medicine is used with traditional medicine, alternative medicine is used in place of traditional medicine. People with breast cancer are advised to talk to their healthcare provider before starting any alternative therapies during their breast cancer treatment.

Relaxation techniques

The following relaxation techniques are designed to relieve stress:

  • Acupuncture
    Acupuncture inserts sharp, thin needles into the body to adjust the body's energy flow into healthier patterns.
  • Biofeedback
    Biofeedback uses special equipment to train people how to regulate their involuntary body functions related to stress, such as heart rate, blood pressure, or brain wave patterns. Biofeedback techniques are able to produce a modest reduction in blood pressure.
  • Deep breathing
    Deep breathing (diaphragmatic breathing) is a relaxation technique that involves breathing deeply into the lungs by flexing the diaphragm instead of the shallower flexing of the rib cage.
  • Hypnosis
    Hypnosis is a trance-like state of high concentration between sleeping and waking that can be used to alter a person's awareness of pain. People are either hypnotized by a trained person (such as a psychologist or psychiatrist) or can be trained to hypnotize themselves.
  • Imagery
    Imagery is using the imagination to create mental pictures or situations to reduce pain.
  • Qi gong
    Qi gong is an ancient Chinese system of breathing techniques, exercises, meditations, and postures designed to improve and enhance the body's health and vitality.
  • RESPeRATE Blood Pressure Lowering Device
    RESPeRATE is an FDA-approved portable electronic device that helps relieve stress naturally by helping people to master the technique of paced breathing.
  • Yoga
    Yoga is a Hindu system that is believed to prevent diseases by a combination of breathing techniques, meditation, and physical exercises designed to strengthen the body and calm the nervous system.

Vitamin D and sunshine

A recent study indicates that people can reduce the risk of breast cancer by:

  • Taking 2000 IU/day (international units) of vitamin D.
  • Spending few minutes in the sun each day with at least 40% of the skin exposed, unless the person has a history of skin cancer or a photosensitivity disease.