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UNDERSTANDING CANCER Breast Cancer Te Matepukupuku o ng A guide for women with breast cancer Copyright 2011 Cancer2011 Cancer Society New IncInc IncInc Copyright 2011 Cancer Society New Zealand Zealand Copyright 2011 Cancer Society ofZealand Zealand Copyright Society of of New of New POPO Box 12700 Wellington 6011. 6011. Box 12700 Wellington 6011. POPO Box 12700 Wellington 6011. Box 12700 Wellington Fifth Edition 2011 Fifth Edition 2011 2011 Fifth Edition Fifth Edition 2011 ISBN 0-908933-91-6 ISBN ISBN 0-908933-91-6 0-908933-91-6 ISBN 0-908933-91-6 Publications StatementStatement Publications Statement Publications Statement Publications The Cancer The Cancer Society s aimtoeasy-to-understand and accurate accurate information on on cancer The Cancer Society s aimto aim is is provide easy-to-understand and informationinformation cancer The Cancer Society s provide toeasy-to-understand and accurate accurate on on cancer Society s aim is is to provide provide easy-to-understand and information cancer and its its treatments. and treatments. treatments. and its its and treatments. Our Understanding Cancer informationinformation booklets are reviewed every four cancer doctors doctors Our Understanding Cancer information booklets are reviewed every every four cancer doctors doctors Our Understanding Cancer information booklets are reviewed four years by years cancer Our Understanding Cancer booklets are reviewed every four years by years by by cancer specialistspecialist nurses and relevant healthhealth professionals to ensure thethe informationreliable specialistspecialist nurses and other relevant health professionals toinformation is reliable is reliable nurses and other relevant health professionals to ensure thethe information is reliable nurses and other other relevant professionals to ensure ensure information is evidence-based and up-to-date. The booklets bookletsreviewedreviewed by consumers to ensure they meet evidence-based and up-to-date. The booklets bookletsreviewedreviewed by to ensure they ensure they meet evidence-based and up-to-date. The areare also are also consumers consumers to meet evidence-based and up-to-date. The also are also by by consumers to ensure they meet thethe needs peopleof people by cancer. cancer. needs ofthe peopleof people by cancer. cancer. the needs affected affected by by of needs affected affected This editionThis edition Breast Cancer Te Matepukupuku includes includes new in responseresponse to to This edition Breastof of BreastMatepukupuku o ng o ng new features features in in response This edition Cancer Te Cancer Te Matepukupuku includes includes new in response to of of Breast Cancer Te Matepukupuku o ng o ng new features features to suggestions suggestions who review whobooklets booklets andthethe meet the ourof our Our key Our key suggestions from those those who review our and to meetand meet the our readers.our Our key Our key suggestions from who review our booklets booklets to needs of needs readers. readers. from those from those our review our and to meet to needs of needs of readers. messages and important sections have been translated into te Reo Mori. Our translationstranslations have messages and important sections have been translated into te Reote Reo Mori. Our translations have messages and important sections have been translated into Mori. Our translations have messages and important sections have been translated into te Reo Mori. Our have been providedprovided by MacDougallMacDougall Wharetuna Mori Consultancy Services. been providedprovided Hohepa MacDougall of of Mori Consultancy Services. Services. been by Hohepa by MacDougall Wharetuna Wharetuna Mori Consultancy been by Hohepa Hohepa of of Wharetuna Mori Consultancy Services. Other titles fromtitles from the Society New Zealand Te Khui Matepukupuku o Aotearoao Aotearoa Other titles titles from the Society of of New Zealand Te Khui Matepukupuku o Aotearoa Other from the Cancer Cancer Society New Zealand Te Khui Matepukupuku o Aotearoa Other the Cancer Cancer Society of of New Zealand Te Khui Matepukupuku Booklets Booklets Booklets Booklets Advanced Cancer Matepukupuku Maukaha Maukaha Advanced Cancer Matepukupuku Maukaha Advanced Cancer Matepukupuku Maukaha Advanced Cancer Matepukupuku Bowel Cancer Matepukupuku Puku Hamuti Hamuti BowelBowel Cancer Matepukupuku Hamuti Hamuti Cancer Matepukupuku Puku Puku Bowel Cancer Matepukupuku Puku Bowel cancer and bowel function function Practical advice BowelBowel cancer and bowel Practical advice cancer and bowel function function Practical advice Bowel cancer and bowel Practical advice Breast Cancer in Men From Men From another another Breast Cancer in Men From From oneto another another Breast Cancer in Men one man one man to Breast Cancer in one man to man to Cancer Clinical Trials Trials Cancer Clinical Trials Trials Cancer Clinical Cancer Clinical Cancer in thethe in thetheTalking your children children Cancer in Family Talking to to your children children Cancer Family Family Talking your Cancer in Family Talking to to your Chemotherapy Hahau Chemotherapy Hahau Chemotherapy Hahau Chemotherapy Hahau Complementary and Alternative MedicineMedicine Complementary and Alternative MedicineMedicine Complementary and Alternative Complementary and Alternative Eating Well Eating Well during Cancer Treatment Kiateiw w Maimoatanga Matepukupuku Eating Well during Cancer Treatment Kia PaiKaiKai tete Maimoatanga Matepukupuku Eating Well during Cancer Treatment Kia PaiPaiKaiKai iw w Maimoatanga Matepukupuku during Cancer Treatment Kia Pai te te i te i te te Maimoatanga Matepukupuku Emotions and Cancer and Cancer Emotions and Cancer Emotions and Cancer Emotions Got Water He Wai Got Water He Wai Wai Got Water He Got Water He Wai Kanesa oKanesa o le susu Breast Cancer (Samoan) Kanesa oKanesa o le susu Breast Cancer (Samoan) le susu Breast Cancer (Samoan) le susu Breast Cancer (Samoan) Lung Cancer Matepukupuku Pkahukahu Lung Cancer Matepukupuku Pkahukahu Lung Cancer Matepukupuku Pkahukahu Lung Cancer Matepukupuku Pkahukahu Melanoma Tonapuku Melanoma Tonapuku Melanoma Tonapuku Melanoma Tonapuku Prostate Cancer Matepukupuku Repeure Repeure Prostate Cancer Matepukupuku Repeure Repeure Prostate Cancer Matepukupuku Prostate Cancer Matepukupuku Radiation Treatment Haumanu Iraruke Iraruke Radiation Treatment Haumanu Iraruke Iraruke Radiation Treatment Haumanu Radiation Treatment Haumanu Secondary Breast Cancer Matepukupuku Tuarua - Tuarua - Secondary Breast Cancer Matepukupuku Tuarua - - Secondary Breast Cancer Matepukupuku Tuarua Secondary Breast Cancer Matepukupuku SexualitySexuality and Cancer Hkakatanga memeMatepukupuku SexualitySexuality and Cancer Hkakatanga te te Matepukupuku and Cancer Hkakatanga memeMatepukupuku and Cancer Hkakatanga te te Matepukupuku Understanding Grief Te Grief Te Pmamae Understanding Grief Te Grief Te Mate Pmamae Understanding Mate Pmamae Understanding Mate Mate Pmamae BrochuresBrochures Brochures Brochures Being Active When You Have Cancer Cancer Being Being Active When You Cancer Cancer Active When You Have Have Being Active When You Have Being Breast Aware Aware Being Being Breast Breast Aware Aware Being Breast Bowel Cancer Awareness Awareness BowelBowel Cancer Awareness Cancer Awareness Bowel Cancer Gynaecological Cancers Cancers Gynaecological Cancers Cancers Gynaecological Gynaecological Questions You MayYou May To Wish To Ask Questions You MayYou May Ask Ask Questions Wish To Wish To Questions Wish Ask Talking to aTalking a FriendCancer Cancer Talking to a Friend a Friend with Talking to with Cancer Cancer Friend to with with Thermography Thermography Thermography Thermography Breast cancer This booklet has been prepared to provide you with information about cancer of the breast. It gives information about diagnosis treatment practical support and the emotional impact of cancer. A specific booklet covering secondary breast cancer is available from your local Cancer Society or by phoning the Cancer Information Helpline 0800 CANCER (226 237). In the past breast cancer surgery was quite extensive and women feared not only the disease but also the treatment. Today with early detection methods and the trend towards smaller operations breast cancer can be treated successfully with better cosmetic results. We can t advise about the best treatment for you personally. You need to discuss this with your own doctors who are familiar with your full medical history. However we hope this information will answer some or your questions and help you think about the questions you may want to ask your doctors. If you find this booklet helpful you may like to pass it on to your family and friends who might also find it useful. The words in bold are explained in the glossary at the end of this booklet. 1 Te matepukupuku o ng Ko te kaupapa o tnei puka he whina i te iwi kia puta whnui ng mramatanga m tnei mate te matepukupuku o ng . He prongo kei roto m te whakatau mate te maimoatanga ng whina i ng pnga o te mate nei ki te taha kikokiko ki te taha wairua. I tua atu ka taea te tono i ttahi puka an m te matepukupuku tuarua o ng mai i te tari o te Khui Matepukupuku tata ki a koe waea rnei ki Waeawhina Prongo Matepukupuku 0800 CANCER (236 237). Hei ng r ki mua he hua whrahi tonu ng pokanga matepukupuku me te kaha mataku o ng whine ki te mate nei tae noa ki ng maimoatanga. I nei r n runga i ng huarahi kite moata me te ia kia iti ake ng pokanga ka angitu ake te maimoatanga me te pai ake o ng huanga whakanako. Kore e taea e mtou te tohutohu i a koe e pa ana ki ng maimoatanga pai mu. Me krero k koe ki rata ina r kei a rtou ng krero e p ana ki t mate. Hunga tr ko te tmanako m tnei puka ka taea tahi o ptai te whakautu me te awhina i a koe ki te whakaaro ake ki tahi ptai hei ptai mu ki t rata. Mehemea i whai whina koe i te puka nei me tuku ki t whnau me hoa tr pea he whina kei roto m rtou. Ka taea ng whakamrama m ng kupu miramira i te rrangi kupu kei te pito o te puka. 2 Contents What is cancer Your breasts What is breast cancer Diagnosis Planning treatment Treatment Making decisions about treatment After treatment Support What can I do to help myself Relationships and sexuality Questions you may wish to ask Glossary Suggested reading and websites Feedback 4 7 9 14 20 23 55 62 68 80 88 91 95 99 105 3 What is cancer Cancer is a disease of the body s cells. Our bodies are always making new cells to replace worn-out cells or to heal damaged cells after an injury. This process is controlled by certain genes the codes that tell our cells how to grow and behave. Cancers are caused by damage to these genes. This damage usually happens during our lifetime particularly as we get older. A small number of people inherit a damaged gene from a parent. Normally cells grow and multiply in an orderly way. However damaged genes can cause them to behave abnormally. They may grow into a lump which is called a tumour. Tumours can be benign (not cancerous) or malignant (cancerous). Benign tumours do not spread to other parts of the body. The beginnings of cancer 4 Malignant tumours invade into the surrounding tissues and may form a secondary cancer or metastasis in another part of the body. For a cancer to grow bigger than the head of a pin it must grow its own blood vessels. This is called angiogenesis. Sometimes cells break away from the original (primary) cancer and spread to other organs. When these cells reach a new site they may form a new tumour. This is called secondary cancer or metastasis. So for example if breast cancer spreads to the bones it is called a breast cancer secondary in the bone. It is not considered to be bone cancer which is a separate disease. He aha te matepukupuku He mate te matepukupuku ka pa ki ng ptau o te tinana. E kore e mutu te mahi a te tinana ki te hanga ptau hou hei whakahou i ng putau kua ruha ki te whakaora hoki i ng ptau kua h i ng wharahanga noa. Whakahaerehia ai tnei mahi e tahi ira ara ko ng tohu ka whakarite i te ahua tipu a ng putau tae noa ki tna whanonga. Ka puta te matepukupuku n runga i ng wharanga ki nei momo ira. Ka p nei wharahanga puta noa i te koiora o te tangata ina koa ka kaha ake te p ka pakeketia ana. Tr tahi tngata torutoru nei ka whnau mai ki te ao me ttahi ira h i heke mai i ttahi o rtou mtua. 5 Ko te tikanga ka tipu pai ka rahi haere ng ptau. Heoi ka tareka e te ira h te whakararu i te mahi a ng ptau. Tr pea ka tipu hei puku kia hoki tnei he puku. Ko tahi puku he mrire (kore matepukupuku) ko tahi he marere (kawe matepukupuku). Kaore ng puku mrire e hrapa ki tahi atu whi o te tinana. Ka whakaeke ng puku marere ki roto i te kikokiko e karapoti ana tr pea ka tipu mai he matepukupuku tuarua ka kia he metastasis ki whi k o te tinana. Kia tipu ai te matepukupuku kia nui ake i te khao o te ngira me whakatipu ano ia i tahi ia toto. Kia ai tnei ko te angiogenesis. Hei tahi w ka maunu mai tahi ptau i te whi tipu taketake (matua) o te matepukupuku ka hrapa ki tahi atu whkau. Ka tau ana nei ptau ki ttahi whi hou tr pea ka tipu mai he puku hou. Kia ai tnei ko te matepukupuku tuarua ko te metastasis rnei. Hei tauira ki te hrapa atu te matepukupuku i te ki ng kiwi kia ai ko te matepukupuku tuarua i te kiwi. Ehara tnei i te matepukupuku ki ng kiwi he mate atu an tr. 6 How cancer spreads Your breasts Your breasts are designed to make milk after pregnancy. The breast tissue extends almost to the collar bone at the top and to the armpit at the side. Lying beneath the breasts are the chest muscles and ribs. Breast tissue is made up of milk glands connective tissue and fat. The milk glands consist of milk sacs (lobules) where milk is made and ducts which take the milk to the nipple. 7 In your breast area and armpit there are lymph glands or nodes which are connected by a system of lymph ducts. These glands and ducts are part of the lymphatic system which helps your body to fight infection. Your breasts do not stay the same throughout your adult life. Your monthly period pregnancy age and weight changes can all alter their shape. Some women find their breasts feel more tender and lumpy before their period. This tenderness and lumpiness disappears after the period ends. This is quite normal. Ko te mahi a ng he waihanga wai whai muri i te haptanga o te wahine. Ka toro te kikokiko o ng ki te thei ki runga ki ng kk i ng taha. Kei raro iho i ng ko ng uaua o te uma ko ng rara. Hangaia ai ng kikokiko mai i ng repe wai ng pnga kikokiko me te mmona. He kahu wai (lobules) ng repe wai he whi mahitia ai te wai ko te whi hoki noho ai ng ngongo kawe i te wai ki ng kmata o ng . Ehara i te mea ka rite te hua o ng puta noa i te wa o t pakeketanga. Ka panoni ng o te wahine n te rere o te toto ia marama n te haptanga n te hipanga o ng tau n te piki me te heke hoki o te taumahatang. Hei mua i te rerenga o te toto ia marama ka ngohengohe ka pupuke ng o tahi whine. Mutu ana te rere o te toto kua kore haere te ngohengohe me te pupuketanga. He mea puta i ng wa katoa. 8 What is breast cancer Breast cancer is a malignant tumour that starts in the breast tissue. The majority of breast cancers begin in the milk ducts (ductal cancers). A small number start in the milk sacs or lobules (lobular cancers). Within these two groups there are different subtypes of breast cancer. Some grow very slowly. Others develop more rapidly. Breast cancer can spread to the lymph glands and to other parts of the body most commonly the lung bones and liver. He aha te matepukupuku o ng He puku marere te matepukupuku o ng ka tmata ki roto i te kikokiko . Ka tipu te nuinga o ng matepukupuku o te ki ng ngongo wai (kia ai he matepukupuku ki te ngongo wai). Ruarua noa ng matepukupuku o te ka tipu i ng ngongo wai ki ng lobules (matepukupuku lobular). Kei roto i nei mate e rua nei tahi atu momo matepukupuku o ng . He pturi te tipu o tahi o ng momo matepukupuku he kakama te tipu o tahi atu. Tr pea ka hrapa te matepukupuku o ng ki ng repe waitinana me tahi atu whi o te tinana tae noa ki ng pkahukahu ki ng kiwi me te ate. 9 fatty tissue invasive breast cancer (cancer cells have spread from milk ducts into the surrounding breast tissue) muscle (milk sacks) lobules (your breast sits on top of a layer of muscle) milk ducts nipple ribs (the muscle sits on top of your ribs) ductal carcinoma in situ (cancer cells are contained within milk ducts) Illustration of a woman s breast showing ductal carcinoma in situ and invasive breast cancer This diagram is reproduced with permission from the National Breast and Ovarian Cancer Centre. 10 How common is breast cancer Breast cancer is the most common cancer in New Zealand women. Approximately 2 500 women are diagnosed each year. Breast cancer can occur at any age but is most common in women between the ages of 50 to 70 years. Although it is very unusual men can develop breast cancer (approximately 1 percent of all breast cancer). For information on male breast cancer contact your local Cancer Society phone the Cancer Information Helpline 0800 CANCER (226 237) for a copy of our booklet Breast Cancer in Men From one man to another. This booklet can also be viewed on the Cancer Society s website (www.cancernz.org.nz) under Cancer Information . Phea te hrapa o te matepukupuku o nga Ko te matepukupuku o ng te matepukupuku nui rawa ka p ki ng whine o Aotearoa. whiwhiwhi ki te 2500 ng wahine ka whakataungia ia tau. Ka p te mate nei ki te wahine ahakoa he aha te pakeke heoi ka kaha rawa te tipu i ng whine e 50 70 tau te pakeke. Ahakoa te rerek ka p an te matepukupuku e ki te tne (tata ki te 1 rau o ng matepukupuku katoa). M te roanga ake o ng krero mo te matepukupuku o ng tne whakap atu ki te Khui Matepukupuku kei t rohe me waea atu rnei ki te Waeawhina Prongo Matepukupuku 0800 CANCER (226 237) m ttahi kape o t mtou puka Breast Cancer in Men From one man to another. Ka taea hoki te pnui i tnei puka i runga i te paetukutuku a te Khui Matepukupuku (www.cancernz.org.nz) i raro i Cancer Information . 11 What causes breast cancer The causes of breast cancer are not clear so there is no certain way to prevent it. There are some clues or risk factors about who is more likely to develop the disease. The risk factors include age a woman s chances of developing breast cancer increase as she gets older previous breast cancer atypical hyperplasia (increased number of abnormal cells) can be seen in breast biopsy a family history of breast cancer having a faulty BRCA gene. The BRCA1 gene when working normally helps to repair DNA having an altered gene that is associated with the risk of breast cancer hormone replacement therapy alcohol consumption obesity. The risk from family history depends on the number of relatives affected whether they are close relatives the age of the relative(s) when their breast cancer was found. 12 However a family history of breast cancer does not necessarily mean a woman will develop breast cancer. Women who are shown to have inherited one of the faulty genes (for example BRCA) associated with breast cancer do have an increased risk. If it seems possible that you may be a member of a family at increased risk you will be referred to a family cancer genetic clinic. Most women who develop breast cancer have no family history of the disease. N te aha te matepukupuku o ng Kore i te mrama ng takenga o te matepukupuku o ng n reira kore he tikanga kaupare hngai rawa atu. Ka puta he twhiri he ahuataga mrearea rnei m ng tngata tr pea ka whakahiato i te mate nei. Ko ng ahuatanga mrea ko nei te pakeke ka pakeke haere te wahine ka nui atu te tponotanga ka tipu te matepukupuku o ng te pnga o te matepukupuku o ng i mua atypical hyperplasia (kua piki te tipu o ng ptau tino rerek) kitea ai i roto i ng biopsy kua p k te matepukupuku o ng ki te whnau te whai ira BRCA muhu (mena kai te mahi tika te ira BRCA1 ka whina ia i ng mahi whakatikatika i te ptau ira (DNA) te whai ira rerek kua whakahngaitia ki te mrea o te puta o te matepukupuku 13 haumanu taiaki whakahoki te kai waipiro te tino mmona. Ka hngai te mrea ka ahu mai i te whakapapa ki nei huatanga te nui o ng whanaunga i pngia ki tnei mate mehemea he whanaunga ptata te pakeke o ng whanaunga i te w i kitea te matepukupuku. Oti r ehara i te mea ka puta te matepukupuku ki te wahine mn kei roto i tna whakapapa. Heoi an r mn kua heke iho te ira h e hngai ki te matepukupuku pr ki te BRCA ka piki te mrea. Mehemea n ttahi whnau koe e kawe ana i taua mrea ka tohua koe ki te haere ki ttahi whare haumanu ira matepukupuku -whnau. Ko te maha o ng whine ka puta te matepukupuku kore he whakapapa o te mate ki roto i te whnau. Diagnosis Symptoms Breasts undergo changes throughout a woman s life particularly the normal changes experienced during the menstrual cycle. 14 When I was diagnosed I felt totally shocked. I couldn t remember much after I heard the word cancer . I was so pleased I had my partner there to write down what was said. Mayuri Some breast changes may be early signs of breast cancer including a lump or lumpiness thickening of the tissue nipple changes for example a blood-stained discharge from one nipple an inverted nipple (unless the nipple has always been turned in) and a rash on a nipple skin dimpling a change in shape a painful area a rash or red marks which appear only on the breast. Although these changes do not necessarily mean you have breast cancer any breast change should be checked by a doctor. 15 Whakatau mate Ng tohumate Ka panoni ng puta noa i te koiora o te wahine tae atu ki ng panonitanga i te w ka heke na toto. Tr pea ko he tohu tahi o ng panonitanga ki ng i ttahi tohu ipu haere o te matepukupuku o ng pr i ttahi puku pupuketanga ranei te mtotoru haere o ng kikokiko te panoni o ng kmata hei tauira te rere o te toto i ttahi o ng he kmata kua huri karo rnei (i puta k rnei tnei hua i te whnautanga mai) he kpukupuku i runga i ttahi o ng kmata te komekome o te kiri te rerek o te hua hanga te mamae ki ttahi whi he kpukupuku he waitohu whero rnei ka puta ki ng . Ehara i te mea he tohu nei kua pngia koe i te matepukupuku o ng engari me tirohia ng rereketanga kua puta ki ng e te Rata. Mehemea kua rerek te hua o tr pea ka whakahaerehia tahi whakamtautau. M t rata ake nei whakamtautau hei whakarite m te mtanga rnei. 16 If you have a change in your breast you may have several tests. Your general practitioner may arrange these tests or you may be referred directly to a breast specialist. Physical examination The doctor will take your medical history and examine your breasts. Diagnostic imaging A mammogram is a breast X-ray. It will give your doctor more information about any lump or other change noticed. Occasionally a lump that can be felt is not seen on a mammogram. Such a lump should not be ignored. Other tests will need to be done. An ultrasound is a test using high frequency sound waves to help detect lumps or other changes. An MRI scan is a scan that uses magnetic resonance to detect abnormalities in the breast. Occasionally an MRI is recommended in young women when their breast tissue is very dense. This type of scan is sometimes used in lobular carcinomas to make sure there is not more than one cancer present and it can check the other breast. It can also be used to check the breast if a mammogram is negative but the specialist is still concerned about the lump or changes in the breast. 17 Fine needle aspiration A fine needle aspiration can be done in your specialist s rooms in a hospital outpatient department or at a laboratory by a pathologist. A very narrow needle is used to take some cells from the lump. These cells are then sent to a laboratory for examination. A fine needle aspiration may cause a little discomfort but is not usually any more painful than a blood test. Results from this test may be available immediately or take some time depending upon where it is done. Biopsy Often a biopsy will be necessary. A biopsy is the removal of a sample of a lump or the entire lump for examination under a microscope. Unuhanga (Biopsy) I te nuinga o te wa me whakahaerehia he unuhanga. Ko te tikanga o te unuhanga ka tangohia he whanga te katoa rnei o te pupuketanga kia ta mtaitia raro i te karuwhakarahi. Core biopsy A larger needle than that used for fine needle aspiration is used to obtain a sliver of tissue from the lump. This is done with a local anaesthetic. It can be done by a radiologist under ultrasound guidance or in a mammogram machine (stereotactic core biopsy). Sometimes it is done by palpation (feeling) of the lump by the specialist. 18 Open biopsy Sometimes a surgical or open biopsy is necessary to remove the whole lump. This small operation is usually done under general anaesthetic although occasionally a local anaesthetic is all that is needed. To have an open biopsy you may need to stay in hospital overnight. Hook wire biopsy If the abnormality in the breast can only be detected by the mammogram (your doctor cannot feel your lump) a fine guide wire may be inserted in the breast to mark the area of the breast to be removed. This takes place in the radiology department under local anaesthetic. The abnormality is then removed as in an open biopsy under general anaesthetic and sent to the laboratory for testing. Further tests If the lump is a cancer hormone receptor tests will be done using immuno-histochemistry (IHC) on the sample that was removed. These tests show whether the cancer cells have special markers on them called hormone receptors (oestrogen progesterone). If these markers are present the cancer is described as hormone receptor positive and the cancer is more likely to respond to hormone treatment if this is needed later. 19 HER2 tests HER2 is a growth factor protein which tells breast cancer cells to grow. Approximately one in five breast cancers makes too much of this protein which means that the cancer is more aggressive. This is often called HER2 positive breast cancer. Two tests are available to check HER2 IHC and FISH. IHC is used first and if it is not a clear result then the FISH test is used. If tests show that you have HER2 positive cancer this will influence future choices of chemotherapy hormones or monoclonal antibodies. The most commonly used monoclonal antibody drug is called trastuzumab (Herceptin) which targets the growth factor protein. A diagnosis of breast cancer (see page 14) can be very stressful (see page 74) for information on the support available). Planning treatment Before any treatment begins make sure that you have discussed the choices with your doctor. Your doctor may advise that one method of treatment is better than another. The treatment choices you are offered will be based on all the information the doctor has about your cancer and what is right for you. These include the size of the cancer the grade of the tumour (how the cancer looks under the microscope. Aggressive cancers have a special appearance that tells doctors they are more likely to spread) 20 the number of lymph nodes under your arm that contain cancer cells whether the cancer was growing into the blood or lymphatic vessels. (This is described as lymphatic vascular invasion (LVI).) whether the cancer cells have hormone receptors (oestrogen progesterone) on them whether there were cancer cells present at the edges of the tissue removed (also called positive margins) HER2 receptor test results (see page 20). your general health. Breast cancer is treated by several different methods surgery radiation treatment chemotherapy hormone treatment and monoclonal antibody therapy. You may find it useful to have your husband partner or a friend with you when you talk to the doctor. You may also find it helpful to make a list of questions before your visit (refer to the list of questions at the end of this booklet and take notes during your discussion). The Cancer Society also has a booklet titled Questions You May Wish To Ask that you can receive from your local Cancer Society by viewing it on our website or by phoning the cancer information nurses on the Cancer Information Helpline 0800 CANCER (226 237). Make sure you understand the reasons for your doctor s advice. Ask for a second opinion if you want one. 21 Te Mahere maimoatanga I mua i te tmatatanga o tahi maimoatanga me matua krero ki t rata e p ana ki ng kwhiringa. Tr pea ka k t rata he pai ake ttahi huarahi maimoatanga ki ttahi atu. Ko ng kwhiringa maimoatanga katoa ka whakaatunga ki a koe ka hngai ki ng prongo e pupuri ana t rata e p ana ki t matepukupuku me ng ahutanga e tika ana mu. He maha ng huarahi maimoatanga m te matepukupuku o ng ko te hparapara ko te haumanu iraruke ko te hahau ko te taiaki ko te haumanu paturopi monoclonal. He pai an pea kia whai t tne t hoa rangatira rnei ttahi o hoa rnei i a koe ki te krero ki te rata. Tr pea ka whakaaro koe m tahi ptai i mua i t haerenga (titiro ki ng ptai kei te pito mutunga o te puka nei tango tuhituhinga i te w o te hui me te rata). He puka t te Khui Matepukupuku e kia ana ko Ng ptai e hiahia ana koe ki te tuku ka taea te tono kia tukuna atu ki a koe ka taea rnei te mtakitaki i runga i t mtou paetukutuku m te waea atu rnei ki te Waeawhina Prongo Matepukupuku. Kia mrama koe ki te take o ng tohutohu a t rata. Ki te hiahia koe me tono i ng whakaaro tuarua a ttahi atu rata. 22 Treatment The treatment team From the time that you are first diagnosed with breast cancer you will be cared for by one or more of a team of health professionals including your family doctor breast care nurses who specialise in the care of women with breast cancer a breast surgeon who specialises in breast diseases and sometimes a (plastic) reconstructive surgeon a pathologist a doctor who diagnoses disease by studying cells and tissues under a microscope a radiation oncologist a doctor who specialises in the use of radiation in the treatment of cancer a medical oncologist a doctor who specialises in the use of drug treatments for cancer radiation therapists who prepare you and give you your radiation treatment oncology nurses who give chemotherapy and monoclonal antibody treatments and support you through your treatment dietitians who will recommend the most suitable foods to eat 23 social workers counsellors physiotherapists and occupational therapists who will advise you on the support services available and help you get back to normal activities. Ideally your hospital should have all available means of diagnosis and treatment although this will not be the case in some areas. Surgery The first treatment for breast cancer is usually surgery. This includes surgery on the breast and for most women some of the glands in the armpit (the axillary lymph nodes) are removed. Examination of the cancer and the lymph glands by the pathologist will indicate whether further treatment should be considered after the surgery. The aim of surgery is to remove all of the cancer. The type of surgery depends on a number of factors including the size of the cancer the size of the breast the position of the cancer in the breast and the patient s choice. Surgery will remove the cancer and a margin of healthy breast tissue around it (wide local excision) or the whole breast (mastectomy). At the same time some of the lymph glands in the armpit are also removed. Studies have shown that women who have a wide local excision followed by radiation treatment (breast-conserving surgery) have the same survival rates as women who have a mastectomy. For more information see the section titled Breast-conserving treatment (wide local excision) . 24 Hparapara Hei te nuinga o te w ko te hparapara te huarahi maimoatanga tuatahi m te matepukupuku . Ka mahia te hparapara ki te ka mutu m te nuinga o ng whine ka tangohia tahi o ng repe i te kk (ng tpona waitinana kk). Waihoki whai muri i te ttari a te pathologist i te matepukupuku me ng repe waitinana e tohu mn ka haere tonu tahi maimoatanga whai muri i te hparapara. E ai ki ng akoranga tiro whnui he rite te oranga o ng whine ka whai tapahitanga whnui me te whai o te maimoatanga iraruke (hparapara pena-) ki era ka whai mastectomy. M te roanga o ng krero titiro ki te whanga e kia ko te Hparapara pena- (tapahitanga -rohe whnui) . 25 Staging breast cancer Staging is a process of assessing the extent of a tumour. Other tests may also be necessary if cancer is diagnosed. These include blood tests and a chest X-ray. In some situations a bone scan and a CT scan of the chest abdomen and pelvis may be done. The complete results from the biopsy and any further tests will help to determine the best treatment for you. With this information your doctors will know if you have an early breast cancer locally advanced breast cancer or metastatic (secondary) breast cancer. Te ttari i te matepukupuku o ng He htepe te mahi ttari hei aromatawai i te whrahi o te puku. Tr pea ka whai atu tahi atu whakamatautau mn kua whakataungia he matepukupuku pr ki ng whakamatautau toto me ng whakaata roto o te uma. M ng putanga o te unuhanga me tahi atu whakamtautau e tohu ko thea te huarahi maimoatanga ka tika mu. M nei prongo ka mrama rata mehemea kua pngia koe ki ttahi matepukupuku tmua o ng rnei te matepukupuku maukaha o ng rnei te matepukupuku tuarua o ng (metastatic) rnei. 26 The following table sets out the breast cancer stages. Stages of breast cancer T N N0 None N1 Up to 3 involved nodes N2 4 or more nodes or fixed nodes N3 Nodes other than in axilla T3 More than (Any nodes) 5cm T4 Fixed to skin or chest wall No metastases M No metastases Early Breast Cancer Stage 1 or 2 T1 2 Tumour up to 5cm (Any size) Locally Advanced Stage 3 No metastases Metastatic Stage 4 (Any size) (Any nodes) Metastases Specialists treat Stages 1 and 2 and early Stage 3 in the same way an operation or operation as well as radiation then possibly other treatments such as chemotherapy hormone therapy or monoclonal antibody therapy according to the woman s cancer. When the tumour is too large to remove by surgery chemotherapy may be used. This is to shrink the cancer so it can be more easily removed by surgery. 27 TNM is an international staging system T tumour (numbered 1 to 4 to indicate the size and extent of the tumour). N node (whether or not lymph nodes are affected by cancer). M metastases (the spread of cancer from the breast to other parts of the body). Grading breast cancer The pathologist (the doctor who looks at cancers in the laboratory) grades the cancer according to the way the cancer cells look. The grades are numbered from 1 to 3. The cells of a Grade 1 breast cancer look more like normal breast cells whereas the cells of a Grade 3 breast cancer look very abnormal indicating a faster growing cancer. Mastectomy Mastectomy is the removal of the whole breast including some of the skin and the nipple. The chest muscles are not removed. Some lymph glands in the armpit are also removed during the operation. Usually the lymph nodes are removed through the same incision during this operation. This is called axillary node clearance (or dissection). 28 Mastectomy is less disfiguring than the radical mastectomy of the past. The new type of mastectomy performed today allows for easier breast reconstruction. After mastectomy most women will have a horizontal scar across their chest. Breast reconstruction can be performed for women having mastectomy. This can be done at the same time as mastectomy (immediate reconstruction) or after all the treatments for the cancer are completed as a separate operation (delayed reconstruction). Mastectomy 29 Breast-conserving treatment (wide local excision) For many women it is now possible to have smaller operations such as partial mastectomy (wide local excision). A breast-conserving operation involves removing the breast lump with some surrounding normal breast tissue to ensure a good clearance. Surgery is then followed by radiation treatment to the remaining part of the breast. This is usually six to eight weeks after surgery. Often if chemotherapy is also needed radiation treatment will be delayed until after chemotherapy treatment is finished. This significantly reduces the risk of cancer recurring in the remaining breast tissue. Breast-conserving treatment 30 Lymph glands are also removed for examination in these smaller operations and this is often through a separate incision (cut) in the armpit. Breast-conserving operations have been routinely performed now for many years. Breast-conserving surgery followed by radiation treatment is as effective as mastectomy for most women with early breast cancer. However with breastconserving surgery followed by radiation treatment there is a higher chance that the cancer could come back in the breast area. This is called local recurrence and does not increase the chance of cancer spreading to other parts of the body. Checking for local recurrence is one of the reasons why followup tests are important after treatment for breast cancer. Checking the lymph nodes under the arm Women with early breast cancer will have their lymph nodes in their armpit checked for spread of breast cancer cells. This is usually done by sentinel node biospy or lymph node dissection. 31 Sentinel node biopsy A sentinel node biopsy locates the first lymph node(s) that drains from the area where the breast cancer developed. This node(s) is detected after injecting a blue dye and a radioactive tracer into the breast tissue where the cancer was found. The node(s) is then removed surgically so that the tissue can be examined. It is thought that removing this node(s) alone may avoid larger operations in the armpit (called axillary clearance). This will reduce the likelihood of surgical side effects (for example lymphoedema). It is also an accurate way of checking if cancer has spread to the lymph nodes. If the sentinel node shows cancer cells the surgeon will need to remove further lymph nodes from the armpit usually 10 to 20 nodes (axillary clearance). This may be done at the same time or in a separate operation. Sentinel node biopsy is not always possible if there is a larger cancer (greater than 3cm) or more than one cancer (known as multifocal) in the breast. Lymph node dissection (axillary clearance) is the removal of lymph nodes in the armpit that could drain breast tissue. There are usually more than 10 glands removed and care is taken to avoid damage to nerves and blood vessels. There is usually a plastic tube called a drain left in the armpit after axillary clearance. The drain is removed when fluid reduces to a very small amount after surgery. Side effects of axillary clearance include shoulder stiffness nerve pain or numbness in the upper arm and lymphoedema. 32 33 Unu tpona sentinel Ko te mahi a te unuhanga tpona sentinel he rapu i te tpona waitinana tuatahi e rere ana i te whi tmata ai te matepukupuku o ng . Ka kitea tnei tpona m te wero i te tae kikorangi me ttahi mtai iraruke ki te whi o te i kitea ai te matepukupuku. Ka tapahia te tpona kia taea taua whi o te te ttari. Ko te whakapae ka tangohia te tpona kia kore ai e pokaina te kk. M tnei ka iti ake ng pnga o te pokanga ka puta ki te taha pr ki te pupuhitanga (lymphoedema). He huarahi tika hei tirotiro mehemea kua hrapa te matepukupuku ki ng tpona waitinana. Drainage after breast surgery After your operation you may have one or two tubes (drains) coming from the area of your operation into small bags. These drain fluid which if not removed can cause discomfort delay wound healing and may cause an infection. They are usually left in place for a few days. Many women are discharged with their drains in place. If this happens your nurse will show you how to care for them at home. Your doctor will arrange for them to be removed at a later date or this may be managed by a district nurse. Removing the drains is quick and causes only mild discomfort. It can be done at the doctor s rooms or at the outpatients clinic. 34 Advantages and disadvantages of surgical methods While many women may want a breast-conserving operation the choice between a mastectomy and a breast-conserving operation depends upon the size of the breast cancer and the size of the breast. It is helpful to weigh up the advantages and disadvantages of each method for yourself. The main advantage of the smaller operation is that the breast is saved. However a disadvantage is that further treatment with radiation treatment is almost always needed. This can take up to six weeks. In the future a small number of patients with small tumours may be candidates for partial breast irradiation. Small-breasted women may also find that the smaller operation still leaves them with a big change in their breast shape. An advantage of mastectomy is that radiation treatment may not be needed. However in some cases if the tumour is large close to the underlying muscle or if there are many lymph nodes involved radiation treatment is still recommended to reduce the risk of cancer recurring. 35 The main disadvantage of mastectomy is the loss of the breast. Reconstruction is possible and can be carried out at the time of the mastectomy or in the future. In some small-breasted women mastectomy and reconstruction will give a better cosmetic result than breast-conserving surgery. Side effects of surgery Side effects of surgery may include wound infection the wound may feel tender swollen and warm to touch. There may be redness in the area and or discharge from the wound. You may feel unwell with a fever and need antibiotics. bruising and haematoma (a collection of blood within the tissues surrounding the wound causing swelling discomfort and hardness). The body will reabsorb the blood within a few weeks. pain if you have lymph glands removed you are more likely to have pain in the armpit or down the arm. You will be advised about exercises to reduce pain and improve arm movement after surgery (see the arm care section later in this booklet on page 63). cording a pain like a tight cord running from your armpit down your upper arm and through to the back of your hand. Cording is thought to be due to hardening of the lymph vessels. Cording may restrict movement and may continue for many months (physiotherapy and exercise may help). 36 Photographer Louise Goossens Image above Information from the planning CT scan and or simulator is used to create an individual map of where the radiation will be delivered. reduced sensitivity of the inner side or down the back of your upper arm due to nerve damage may sometimes occur. This is usually temporary and improves or disappears about three months after surgery. some women have a swelling caused by fluid build up (seroma) that may need to be drained several times over a period of days or weeks. swelling of the arm (lymphoedema) may occur in some women after lymph glands have been removed from the armpit. Occasionally this swelling can extend into the chest wall or abdomen (see the arm care section on page 63). 37 Photographer Louise Goossens Image above The radiation therapist will explain your treatment to you. reduced range of movement in the shoulder. You will be given an exercise programme to improve this after surgery. Sometimes a physiotherapist will help you with this. Discuss possible side effects with your doctor before your operation. Report any problems that occur after surgery to your breast care nurse or doctor. After your cancer has been removed your surgeon will discuss your tumour with other specialists to determine what further treatment if any will be recommended. For additional practical tips regarding breast surgery phone the cancer information nurses on the Cancer Information Helpline 0800 CANCER (226 237). 38 My whole breast was sore it was so uncomfortable but the nurses put on me this beautiful dressing. And I loved that dressing. Silei Radiation treatment This is the use of radiation (rays of energy called photons or little particles called electrons) to destroy cancer cells usually using a machine called a Linear Accelerator. You will see a radiation oncologist who will discuss this treatment with you. Treatment is carefully planned to reduce any effect on normal cells. Before you start a course of radiation you will need at least one visit to the cancer centre to work out the exact position you will lie in during treatment (this is called simulation). Simulation involves a CT scan and a computerised treatment plan. Treatment is given four to five days a week over about four to five weeks. It is painless and only takes a few minutes for each treatment. 39 (c) Photographer Louise Goossens Image above The Linear Accelerator is positioned to deliver treatment to where it is needed. (c) There is a handle to hold as well as supports under the arms so you can just lie back and relax. An extra radiation boost dose may be given to the area where the breast cancer was located taking the overall treatment time up to five to six weeks. Giving radiation to part of the breast (partial breast irradiation) is currently being investigated as an alternative to giving radiation to the whole breast in certain patients. Radiation is routine if a wide local excision is carried out. 40 It s like an X-ray machine. No worries. You ve got a comfortable room music going then it s over. Milly Sometimes radiation is given after mastectomy and axillary surgery to reduce the likelihood of developing recurrence in over the chest wall or in the axillary or supraclavicular (above the collar bone) lymph nodes. This decision is usually made once the results of the surgery are available and the risks for recurrence in these sites have been assessed. Radiation may also be used for the treatment of recurrence or cancers that cannot be removed either in the area of the breast or in other parts of the breast. The aim is to try to control the disease or reduce symptoms. This usually requires fewer visits. 41 Haumanu iraruke Ko t tnei he whakamahi i te iraruke (he hihi pngao kia ai he photon he tpata iti e ki ana he irahiko) hei patu i ng ptau matepukupuku m te whakamahi i ttahi mhini kia ai he Linear Accelerator. Ka krero ttahi kaimtai matepukupuku iraruke ki a koe m tnei huarahi maimoatanga. Ka ata maheretia te maimoatanga hei whakaiti i te pnga ki ng ptau pai. I mua i te tmatatanga o ttahi whakahaere iraruke me haere koe ki te pokap matepukupuku ki te whakarite i te takotoranga ka whai koe i te wa o t maimoatanga (kia ai tnei ko te whaihanga) kei roto i te mahi whaihanga ko matawai roro me ttahi mahere maimoatanga kua rorohikotia. Ka whakamahia antia te iraruke m ng matepukupuku ka hoki mai ki te rohe o te uma ki whi k rnei o te uma kore e tareka te tango. Ko te whinga kia tmia te mate kia whakaitia rnei ng tohumate. Ko te tikanga ka iti ake ng wa whakamahia ai. Side effects of radiation treatment Early side effects of radiation treatment most of which are short term may include general tiredness some reddening or sunburning of the skin Follow the advice of your radiation therapists on skin care and underarm hygiene. 42 I d always been proud of having really long hair and I think I coped well. I got it cut shorter and shorter as I came up to treatment. June your breast may feel firmer. If you are having radiation treatment you should get extra rest and regular exercise to help cope with the tiredness. Try to wear loose cotton clothing whenever possible to reduce any irritation to the area having the radiation. Talk with your doctor or the radiation treatment staff about any possible side effects and how to manage them. Phone your local Cancer Society for a copy of the booklet Radiation Treatment Haumanu Iraruke download the booklet from our website www.cancernz.org.nz or call the cancer information nurses on the Cancer Information Helpline 0800 CANCER (226 237) for a copy. Late side effects which develop many months or years later may include skin changes changes in size shape colour or feel of the breast. Radiation to the lymph nodes can increase the risk of developing lymphoedema. 43 Photographer Louise Goossens 44 If you live a long way from the nearest cancer centre you will need to stay nearby during your radiation treatment. Oncology centres have special accommodation close by. Chemotherapy This is the treatment of cancer with drugs. The aim is to destroy cancer cells while having the least possible effect on normal cells. The drugs are usually given intravenously via a drip and circulate around the body. Chemotherapy is a systemic treatment (treating the whole body) compared with surgery and radiation treatment which are local treatments to a specific area in the body (for example breast chest wall and axilla). There are different regimens or combinations of drugs used in breast cancer. Most will contain an anthracycline drug for example doxorubicin (Adriamycin). If there is a greater risk of spread and therefore greater benefit from chemotherapy taxanes for example paclitaxel (Taxol) or docetaxel (Taxotere) may be used. Treatment is often in cycles at three-weekly intervals and may last for several months. A medical oncologist will discuss all aspects of the treatment with you. Chemotherapy is offered to some women with early breast cancer as an additional treatment to surgery radiation treatment or both. This is called adjuvant chemotherapy. Adjuvant chemotherapy aims to destroy cancer cells that remain in the body which cannot be detected. In time these cells will grow to form a recurrence of the breast cancer. 45 The purpose of adjuvant treatment is to reduce the chance of that happening. Radiation treatment if it is necessary comes after chemotherapy starting about four weeks after the last cycle of chemotherapy. Hormone therapy if recommended may begin either before or after the radiation treatment. Women who will most likely benefit from chemotherapy are women with cancer cells in the lymph glands in their armpit some women with more aggressive cancers (Grade 3) with no spread of cancer to the lymph nodes women who are HER2 positive (chemotherapy given with trastuzumab (Herceptin)). In some cases of larger tumours where women wish to try to avoid mastectomy neo-adjuvant chemotherapy may be used. Chemotherapy before surgery (neo-adjuvant chemotherapy) Women with a cancer called inflammatory breast cancer are normally offered chemotherapy before surgery. This is called neo-adjuvant chemotherapy. Neo-adjuvant chemotherapy is also used when women have tumours that are large and have to be reduced in size before successful surgery is possible. 46 I was determined I wasn t going to look sick. I did my hair and wore makeup during treatment. These little things helped me feel better about myself. Jillian Hahau He patu i te matepukupuku m te rongo te tikanga o tnei huarahi maimoatanga. Ko te whinga ko te patu i ng ptau matepukupuku me te aro ki te tiaki i ng ptau pai. Ka whakaurua te rongo m te whngai--iaia m ttahi turu m reira ka hurihuri haere i te tinana. He maimoatanga -pnaha te hahau (ko te maimoa i te tinana katoa) mn ki te whakarite ki te pokanga me te maimoatanga iraruke he maimoatanga ki ttahi whi hngai o te tinana pr ki te ng te pt uma me te axilla. 47 Side effects of chemotherapy Chemotherapy side effects vary depending on the particular drugs used. When adjuvant chemotherapy is given to women with breast cancer side effects may include infections the drugs can lower your ability to fight infections. If you are feverish (your temperature is 38 degrees C or more) or if you feel unwell in any way don t wait to see what happens take action immediately. Contact your cancer doctor or nurse and follow the advice given. sore mouth nausea and vomiting loss of appetite or taste changes feeling off-colour and tired temporary thinning or loss of hair. If you have temporary hair loss you are entitled to a benefit to buy a wig. weight gain. This is quite common after chemotherapy so trying to keep up regular exercise is important. difficulty concentrating for some. This is temporary but can take some months after chemotherapy to go away. loss of libido (interest in sex) hot flushes vaginal dryness mood swings or other symptoms of menopause. 48 If you are still having periods you may find that your periods become irregular or stop while you are having treatment. If you are approaching menopause your periods may not return once the treatment has stopped. If you are sexually active with a male partner you and your partner should use a reliable contraceptive such as a diaphragm or condom during treatment because the drugs can cause birth defects or miscarriage. Your ability to become pregnant may be affected. Some women may be permanently infertile (unable to become pregnant). This can be very hard to cope with and it may be helpful to talk with others who have been through this your doctor or to a counsellor or fertility expert. Chemotherapy drugs may have particular side effects and these will be discussed with you. Discuss any side effects with your doctor. Side effects are usually temporary and there are ways of reducing the impact of any unpleasant symptoms. Phone your local Cancer Society for a copy of the booklet Chemotherapy Hahau download the booklet from our website www.cancernz.org.nz or phone the cancer information nurses on the Cancer Information Helpline 0800 CANCER (226 237). 49 Treatment of HER2 positive breast cancer Women with HER2 positive breast cancer are treated with a monoclonal antibody called trastuzumab (Herceptin). Trastuzumab (Herceptin) is given intravenously once every week or three weeks and is usually well-tolerated. Monoclonal antibodies are drugs that recognise and bind to specific proteins (receptors) that are found in particular cancer cells or in the blood stream. In New Zealand trastuzumab may be used for up to one year in early breast cancer. In secondary breast cancer it can be continued until the cancer is no longer responding to it. When this occurs lapatinib (a pill taken by mouth) can be used instead to shrink the cancer usually in combination with further chemotherapy. As of 2011 this medicine is not funded in New Zealand. Trastuzumab may cause some problems with heart pumping function. Before starting trastuzumab treatment your doctor will check your heart using an echocardiogram or a multigated acquisition (MUGA) scan. Your doctor will check your heart at intervals while you are receiving treatment. 50 An echocardiogram will be done every 12 to 18 weeks. Echocardiogram A type of ultrasound test that looks at the size shape and function of the heart. Multi-gated acquisition (MUGA) scan a test that measures how well the heart pumps blood. Monoclonal antibodies Monoclonal antibodies may cause other side effects. Talk to your doctor about these. Ko nei rongo ko ng monoclonal antibodies ka mhio kia piri ki ng pmua ka kitea i tahi ptau matepukupuku i te ia toto rnei. 51 Hormone treatments Many breast cancers appear to be influenced by the female hormones oestrogen and progesterone. Pre-menopausal women may be offered tamoxifen a hormone treatment taken as a tablet. They may also have menopause induced to stop their own production of hormones. This can be done by four-weekly injections with goserelin (Zoladex) or by surgical removal (laparoscopic oophorectomy) of the ovaries. Once you stop taking goserelin your periods will usually return. Post-menopausal women may be offered oral hormone treatments either tamoxifen or aromatase inhibitors for example anastrozole (Arimidex) letrazole (Letara) or exemestane (Aromasin) which reduce the production of hormones in the body (other than from the ovaries). Generally women with breast cancer should not take any hormone replacement therapy or have an interauterine device (IUD) that secretes hormones. 52 Maimoatanga taiaki Te hua nei ka awenga te maha o ng matepukupuku e ng taiaki wahine ar ko te oestrogen me te progesterone. Tr pea ka tpaea te tamoxifen ki ng wahine kre an i tmata te koero. He momo maimoatanga taiaki ka kinga ai pnei i te pire. Tr pea ka poapoatia te koero kia kore ai te tinana e hanga taiaki. Ka tareka tnei m ng werohanga o te (goserelin) Zoladex ia wh wiki m te pokanga (laparoscopic oophorectomy) o ng kiato kkano rnei. Hei te nuinga o te w mutu ana t kai i te goserelin ka rere an toto ia marama. Ka tpaea ng rongo taiaki -waha ki ng wahine kore an i p te koero he tautawhi tamoxifen he tautawhi aromatase rnei pr ki te anastrozole (Arimidex) te letrozole (Letara) te exemestane (Aromasin) rnei ka tmi i te hanga a te tinana i te taiaki ki roto i te tinana (i tua atu i ng kiato kkano). 53 General side effects of hormone treatments Side effects of hormone treatments may include menopausal symptoms such as hot flushes vaginal dryness and mood swings. For suggestions on coping with these it may be helpful to talk to another woman who has been through this or to call your local Cancer Society or phone the cancer information nurses on the Cancer Information Helpline 0800 CANCER (226 237) for more information. The Cancer Society has an Information Sheet titled Cancer and Early Menopause which is available from our website (www.cancernz.org.nz). effects on fertility if you have not reached menopause it may still be possible to become pregnant while you are taking hormone therapies. If you are sexually active with a male partner it is recommended that you use reliable contraception such as a diaphragm or condom. Sometimes you may have permanent menopause as a result of your hormone therapy. (See infertility in the section on Chemotherapy on page 49.) aromatase inhibitors can cause more rapid loss of minerals from bones (osteoporosis) and fractures are slightly more common while on these medicines. It may be recommended that you have a bone density study before starting and at some time during treatment. Treatment may be given for several years. 54 Osteoporosis can be treated with oral bisphosphonates (bone hardening drugs). muscular and joint aches are common side effects of aromatase inhibitors. Hormone drugs may cause additional side effects. Discuss these with your doctor. Making decisions about treatment Sometimes it is difficult to make decisions about what is the right treatment for you. You may feel that everything is happening so fast that you do not have time to think things through. It is important not to be rushed into a decision it must be the right one for you. While some people feel they are overwhelmed with information others may feel that they do not have enough. Understanding your illness the possible treatment and side effects will help you to make your own decisions. If you are offered a choice of treatments you will need to weigh their advantages and disadvantages. You may want to ask your doctor whether the benefits of treatment outweigh the side effects. If only one type of treatment is recommended ask your doctor to explain why other treatment choices have not been advised. 55 Te whakatau ko thea maimoatanga Hei tahi w he uaua te whiriwhiri ko hea te huarahi maimoatanga pai mu. N te tere rawa ka nini te mhunga kua kore e aro me aha. Ko te mea nui kia kaua e pnn i t whakataunga ta whiri i te huarahi tika mu. Talking with doctors You may want to see your doctor a few times before making a final decision on treatment. It is often difficult to take everything in and you may need to ask the same questions more than once. You always have the right to find out what a suggested treatment means for you and the right to accept or refuse it. Before you see the doctor it may help to write down your questions. There is a list of questions at the end of this booklet which may help you. Taking notes during the session can also help. You may find it helpful to take a family member or friend with you to take part in the discussion take notes or simply listen. Some people find it is helpful to record the discussion. 56 My only advice is to talk about it. Be very careful because some people are very forceful. If you listen to everyone the right advice may become apparent whilst the unusual advice will be the stuff you ignore. Rita Te krero me t rata Tr ka hiahia krero koe ki t rata i mua i te whakatau ko hea te huarahi maimoatanga pai mu. Me uaua ka tarea e koe ng krero katoa hei tahi w me hoki atu tuarua tuatoru ptai. Kei a koe te tika ki te rapu he aha ng putanga o ttahi maimoatanga mu ake kei a koe te tika ki te kaupare i te maimoatanga ahakoa he aha taua momo maimoatanga. Talking with others Once you have discussed treatment options with your doctor you may want to talk them over with someone else such as family or friends specialist nurses your family doctor the Cancer Society the hospital social worker or chaplain your own religious or spiritual adviser or another person who has had an experience of breast cancer. 57 Photographer Louise Goossens 58 Talking it over can help you to sort out what course of action is right for you. Family and friends will often give you advice about breast cancer treatment. This can be helpful but remember your cancer is your own . They may be giving you advice about a situation that is different from yours. Te krero ki tahi atu Ina oti whitiwhitinga krero me t rata tr pea ka prangi krero koe ki tahi atu pr i t whnau hoa ng tapuhi te rata o t whnau te Khui Matepukupuku te minita te kaimahi hapori rnei i te hhipera tu ake minita pirihi phopa aha atu ttahi atu tangata rnei kua pngia i te matepukupuku o ng . A second opinion You may want to ask for a second opinion from another specialist. Your specialist or general practitioner can refer you to another specialist and you can ask for your records to be sent to the second doctor. You may be interested in looking for information about breast cancer on the internet. While there are very good websites you need to be aware that some websites provide wrong or biased information. We recommend that you begin with the recommended websites at the end of this booklet (see page 99). 59 Taking part in a clinical trial Research into the causes of breast cancer and into ways to prevent detect and treat it is ongoing. Your doctor may suggest that you consider taking part in a clinical trial. Clinical trials are a vital part of the search to find better treatments for cancer and are conducted to test new or modified treatments and see if they are better than existing treatments. Many people all over the world have taken part in clinical trials that have resulted in improvements to cancer treatment. The decision to take part in a clinical trial is always yours. If you are asked to take part in a clinical trial make sure that you fully understand the reasons for the trial and what it means for your treatment. Before deciding whether or not to join the trial you may wish to ask your doctor Which treatments are being tested and why What tests are involved What are the possible risks or side effects How long will the trial last Will I need to go into hospital for treatment What will I do if any problems occur If the treatment I receive on the trial is successful for my cancer is there a possibility of carrying on with the treatment after the trial 60 If it is a randomised trial you will be chosen at random to receive one treatment or the trial treatment but either treatment should be appropriate for your condition. You won t be able to choose from the treatments offered. In clinical trials people s health and progress are carefully monitored. If you join a clinical trial you have the right to withdraw at any time. Doing so will not jeopardise your treatment. Te whai whi ki te whakamtautau haumanu Kei te haere tonu ng rangahau m te ptake o te matepukupuku o ng tae atu ki ng kauparetanga ng thuratanga ng maimoatanga hoki. Tr pea ka whakataunaki t rata kia kuhu koe ki ttahi whakamtautau haumanu. He whi nui t ng whakamtautau haumanu i te rapunga oranga i te matepukupuku whakahaeretia ai ki te whakamtautau haumanu hou ki te whakamtautau i ng maimoatanga kua whakapanoni ki te kimi mn he pai atu nei momo maimoatanga i ng maimoatanga kei te mahia i nei r. Ka hia tngata puta noa i te ao kua whai whi ki ng whakamtautau haumanu me te aha kua pai atu ng maimoatanga i te matepukupuku. Oti r kei a koe te tikanga i ng w katoa ki te kuhu ki ttahi whakamtautau haumanu ki te kore rnei. 61 After treatment Following treatment you will find your energy will gradually come back. You may need to have extra rest for a while. Increase your exercise and general activities as you feel able. Research has shown that regular exercise during and after treatment is beneficial. The majority of women find they can do most things within a few weeks of surgery. After the completion of your treatment you may need to have regular check-ups. Your doctor will decide how often you will need these check-ups as everyone is different. Check-ups will gradually become less frequent if you have no further problems. Generally women have a yearly mammogram after breast cancer treatment. Many people worry that any pain or illness is a sign that the cancer is coming back. This is usually not the case but if you are worried about whether the cancer is going to come back ask your doctor what to expect. You may feel less worried if you know exactly what to look for and what you do not have to worry about. If the cancer returns you will most likely be offered further treatment. It is important to report any new symptoms to your doctor without delay. You might feel worried or depressed when your treatment is over and have time to realise what has happened to you. You may find it helpful to continue in or join a cancer support group to help you through the months ahead. 62 Whai muri i ng maimoatanga Whai muri i ng maimoatanga me hokihoki koe kia tirohia koe. M t rata e tohutohu kia hia ng w hokihoki ai koe ki ng rata i te mea he rerek tn tangata i tn tangata. Mehemea kei te pai te hauora ka iti haere ng hokinga ki ng rata. Ko tna tikanga ka whai whakaata -tau ng whine whai muri i ng maimoatanga matepukupuku . Arm care and lymphoedema Following your surgery it may take some time to regain the full use of your arm. Your physiotherapist or breast care nurse will give you instructions for exercises. You may be concerned that your arm will swell after your lymph glands have been removed. This is much less common today because of the better methods of surgery and radiation treatment. However a few women will still develop problems with arm swelling (called lymphoedema). To reduce the risk of this happening you should try to avoid injury or infection to your arm or hand. Some simple measures may help Regular exercise is helpful. Wear gardening gloves when gardening an oven glove when handling hot dishes and use a thimble for sewing. If you re out in the sun protect your arm from sunburn by wearing a long-sleeved shirt. Use a good sunscreen (SPF30 ) on uncovered areas. 63 If you have a cut clean it well and use an antiseptic dressing. See your doctor quickly if you think it is infected. Get help with heavy jobs like moving furniture or carrying heavy luggage and avoid using heavy backpacks for any length of time. It is suggested that it may be beneficial to wear a support sleeve when flying. If possible use the unaffected arm to have your blood pressure injections or blood taken from that arm. Be aware of swelling in the arms at any point in the future. Contact your doctor if this occurs. Lymphoedema therapists and physiotherapists can also advise about massage techniques and the need to wear a support sleeve if swelling occurs. Te tiaki ringaringa me te lymphoedema Whai muri i te hparapara ka roa te w ktahi an ka hoki mai te kaha ki t ringa. M t kairomiromi t tapuhi tiaki rnei e hoatu tohutohu m ng mahi korikori tinana. Tr pea ka wangawanga koe m te pupuhi t ringa i te tangohanga o ng repe waitinana. Kua kore e tino pn i nei rangi n runga i te pai ake o ng mahi pokanga me ng maimoatanga iraruke. Heoi an r ka p tonu tnei mate pupuhi ki ng ringa o tahi whine tokoiti nei (kia ai he lymphoedema). Kia iti ake ai te tuponotanga ka puta tnei me kaha te karo i ng wharanga me ng whakapokenga ki t ringa. 64 Breast forms If you have had a mastectomy it s important to know about a breast form (prosthesis). A breast form can give a good cosmetic appearance as well as helping your balance and posture. Many women choose to use a breast form although some women prefer not to. Breast forms are also available for women who have had lesser surgery (partial mastectomy). Immediately after surgery temporary prostheses may be available from your local Cancer Society or breast care nurse. 65 About six weeks after the operation you may choose to wear a permanent prosthesis. You are entitled to a benefit for a permanent breast form. Ask your surgeon or breast care nurse for a medical certificate of entitlement. Hanga Mehemea i whai mastectomy koe he mea nui kia mhio koe m te hanga (kia ai he prosthesis). He pai tonu te hua whakanako o te hanga tae noa ki tna whina i a koe kia mau t whina i te hanga kia pai ai t hua kia pai ai hoki t tauriterite me t t. Ka whai whi koe ki ttahi penihana m ttahi hanga pmau. Me uiui i t rata ki t tapuhi tiaki rnei m ttahi tiwhikete e hei ana koe te tono. Reconstruction After a mastectomy your breast can be reconstructed either immediately or at a later date. A surgeon s decision about which method of reconstruction to recommend is based on many different factors. Reconstruction should be discussed fully with your specialist and you may be referred to a plastic (or reconstructive) surgeon. Many women do not wish to have a reconstruction. Speaking with a breast care nurse or with a woman who has had a reconstruction may be helpful. Information is available from your local Cancer Society or phone the cancer information nurses on the Cancer Information Helpline 0800 CANCER (226 237). 66 Possibility of recurrence Sometimes breast cancer can come back (known as a recurrence). This can be in the breast or in more distant parts of the body. Most recurrences appear within five years after the initial treatment. Regular check-ups are necessary during this period. You should also regularly examine your remaining breast and mastectomy area and report any unusual breast symptoms or general symptoms to your doctor. You will need a yearly mammogram. The risk of a new breast cancer is increased once you ve had breast cancer. Treatment of recurrent breast cancer may be by surgery radiation treatment chemotherapy hormone treatment (refer to pages 23 to 55) or trastuzumab (refer to page 50) or combinations of these. It aims to control the disease. Successful treatment of recurrent breast cancer will allow many women to continue leading normal lives. A specific book Secondary Breast Cancer Matepukupuku Tuarua - is available from your local Cancer Society or by phoning the cancer information nurses on the Cancer Information Helpline 0800 CANCER (226 237). 67 I said to them Look you just have to support me now. It s my time. It was role reversal. Silei Support Emotional support Women react in different ways when they learn they have breast cancer. Feelings can be muddled and change quickly. This is quite normal and there is no right or wrong way to feel. Some women may have particular concerns they may be worried about the change in their appearance after surgery and how it will affect their lives and relationships. Younger women may be worried about fertility pregnancy and breast feeding following treatment (this should be discussed with your specialist). Other women may feel that they are not getting enough personal support to help them deal with their illness. 68 69 It may be helpful to talk about your feelings with your partner family members friends or with a breast care nurse your local Cancer Society counsellor social worker psychologist or your religious spiritual adviser. Talking to other women with breast cancer may also help. Sometimes you may find your friends and family do not know what to say to you they may have difficulty with their feelings as well. Some people may feel so uncomfortable they avoid you. They may expect you to lead the way and tell them what you need. You may prefer to ask a close family member or friend to talk to other people for you. Anyone you tell needs time to take it in and to come back with his or her questions and fears just like you. You can help them to adjust just as they can help you. But remember that while you are having treatment your needs should come first. If you do not feel like talking or you cannot cope with any more visitors say so. If there are practical things they can do to help let them know. Some friends are better at doing something practical to help than they are at sitting and talking. Everyone is different and some may find it so difficult that they stop visiting for a while. Breast cancer and its modern treatment is a huge life journey. You may be shocked about your cancer diagnosis and you may worry about the time it is taking to decide on treatment. This is because your oncologist cannot give you detailed advice about your best choices until the pathologist has reported on your lump or breast tissue the lymph glands and hormone receptors. 70 Your oncologist s advice about which treatment is best for you is based on the size of the cancer how abnormal it is (its grade) whether it has been completely removed whether the lymph nodes have cancer in them or not (and if so how many lymph nodes were involved) whether the cancer had oestrogen (ER) and progesterone (PR) receptors and whether the HER2 receptor is positive. That visit to discuss the pathology report is a huge step and we suggest you take along a person to support you. Many women cope well with the first part of chemotherapy but the length of the programme means that by the end of chemotherapy many women are tired. It is often when the treatment is finished that the full impact of the breast cancer diagnosis and its treatment hits home . Many women feel vulnerable at this time. The family and friends may have moved on but you may feel differently. There may be an impact on relationships sexuality and the ability to work. This vulnerable phase may last 6 to 12 months. The first mammogram is often a hurdle as is the anniversary date of the diagnosis. Your oncology team understands the impact of this journey and can help more if you are open and tell them of your emotional and coping concerns. For details of additional support services available phone the cancer information nurses on the Cancer Information Helpline 0800 CANCER (226 237). 71 Tautoko Ng tautoko o te ngkau He rerek te urupare a tn wahine a tn wahine ki te pnga o te matepukupuku o ng . Ka hurihuri ng whakaaro ka piki ka heke. Ehara i te mea kei te h nei hurihuringa kore e tareka te k kei te tika tnei kei te h tn. Kore e kore he wangawanga ake tahi whine kei te mharahara m te rerek o t rtou hua whai muri i te hparapara tae atu ki te pnga ki rtou koiora me rtou hononga. Tr pea ka wangawanga ng whine rangatahi ake whai muri i te hparapara m rtou whare tangata te haptanga me te whngai tamariki ki te wai (me krero koe ki t mtanga). Tr pea kei te whakapae tahi atu whine kore rtou i te whiwhi whina e tika ana e puta ai rtou i rtou mate. He mea pai pea te krero m u kare -roto ki t hoa tata t whnau hoa te tapuhi tiaki he kaitakawaenga he tauwhiro te kaimtai hinengaro tae atu ki t kaiwhina i te taha wairua. Tr pea he mea whina i a koe te krero ki tahi atu wahine mate i te matepukupuku . Tr pea kore hoa t whnau rnei i te mrama me phea te krero ki a koe. N te kaha mataku o tahi tr pea ka karo haere i a koe. Kei te tatari pea rtou mu ki te rahi i a rtou ki te whki atu he aha hiahia. 72 Tr pea ka hiahia koe ko ttahi o t whnau ko ttahi hoa rnei e t hei kaikrero mu. Ahakoa ko wai te tangata ka krero koe me tuku he w mna ki te whakaaro m tnei take tr pea ka hoki mai a ia me na ptai na mharahara pr i a koe n. Kia maumahara i te w o t maimoatanga me aro koe ki a koe an i te tuatahi. Ki te kore koe prangi krero ki tahi tngata kore rnei koe e prangi ki tahi manuhiri krerotia. Mn ka taea he whina i tahi atu tngata krerotia. He pai atu tahi hoa ki ng mahi tr ki te noho ki te krero me koe. He rerek tn tangata tn tangata n te kaha wehi kore tahi tngata e puta ake kia kite i a koe m ttahi w. Talking with your children How much you tell children will depend on how old they are. Young children need to know that your illness is not their fault. They also need to know that you may have to go into hospital. Slightly older children can probably understand a simple explanation of what is wrong. Adolescent children can understand much more. All children need to know what will happen to them while you are in hospital who will look after them and how their daily life will be affected. Sometimes children rebel or become quiet. Keep an eye on them or get someone else to and get help if you need it for example from the school a counsellor or a hospital social worker. 73 The Cancer Society has a booklet Cancer in the Family written to support parents and carers in the difficult task of talking with your child or children about cancer. To get a copy of this booklet contact your local Cancer Society phone the cancer information nurses on the Cancer Information Helpline 0800 CANCER (226 237) or download it from our website at www.cancernz.org.nz. Cancer Society Volunteering Information and Supportive Care Services Your local Cancer Society provides confidential information and support. The Cancer Information Helpline is a Cancer Society service where you can talk about your concerns and needs with trained nurses. Call your local Cancer Society and speak to supportive care services staff or phone the cancer information nurses on the Cancer Information Helpline 0800 CANCER (226 237). Local Cancer Society centres offer a range of support services for people with breast cancer and their families. These may include volunteer drivers providing transport to treatment accommodation support and education groups contact with other women who have had breast cancer the Look Good...Feel Better workshop. Contact your local Cancer Society about attending this workshop. 74 75 You may be interested in Cancer Connect NZ which arranges telephone peer support calls for people living with cancer and their caregivers. For more information call the Cancer Information Helpline (0800 CANCER (226 237). Cancer Chat is an online support and information forum (www.cancerchatnz.org.nz). The range of services offered differs in each region so contact your local centre to find out what is available in your area. If you are having treatment at a private hospital ask your treatment team what services you may be eligible for. Ng Mahi Tao Ng Pronga me ng Manaaki Tautoko a Te Khui Matepukupuku Whakarato ai t Khui Matepukupuku -rohe i ng prongo matatapu me te tautoko. He ratonga te Ratonga Parongo Matepukupuku n te Khui Matepukupuku ka taea te noho me te krero i wangawanga ki tahi tapuhi matatau ki t mate. Waea atu ki te Khui Matepukupuku i t rohe ka krero ki ng kaimahi waea rnei ki Waeawhina Prongo Matepukupuku 0800 CANCER (226 237). Kei ng pokap Khui Matepukupuku -rohe ng ratonga whina m te hunga kua pngia i te matepukupuku o ng me rtou whnau. Ko tahi o nei whina ko ng kaitaraiwa hei hari i a koe ki ng mahi maimoatanga ng kinga noho ng rp tautoko me ng rp ako 76 The Helpline nurse was great. I rang and said Help I can t do this on my own. Arthurette he whakapnga ki tahi atu whine kua pngia i te matepukupuku o ng te awheawhe Look Good...Feel Better. Whakap ki te Khui Matepukupuku tata ki a koe m tnei kaupapa. Tr pea ka whakaaro koe m Cancer Connect NZ he rp whakarite krero tautoko -hoa m te whakamahi i te waea m te hunga noho matepukupuku me rtou kaitiaki. He wnanga prongo me te tautoko -ipurangi a cancerchatnz. org.nz. He rerek ng ratonga i tn rohe i tn rohe n reira ptai ki te pokap i t rohe he aha rtou ratonga. Mehemea kei te whai maimoatanga koe ki ttahi hhipera tmataiti ptaitai t rp maimoatanga he aha ng ratonga e mraurau ana koe ki te tono. 77 Cancer support groups Cancer support groups offer support and information to people with cancer and their families. It can help to talk to others who have gone through the same experience. Support groups can also offer many practical suggestions and ways of coping. Ask your hospital or local Cancer Society for information on cancer support groups in your area. Breast care nurses A breast care nurse may be available in your hospital to provide specialist support and guidance. Financial assistance Help may be available for transport and accommodation costs if you need to travel some distance to your medical and treatment appointments. Your treatment centre or local Cancer Society can advise you about what sort of help is available. Financial help may be available through your local Work and Income office. Work and Income has pamphlets and information about financial assistance for people who are unable to work. Short-term financial help is available through the Sickness Benefit and longer-term help is provided through the Invalids Benefit. Extra help may be available for example accommodation supplements and assistance with medical bills. 78 More information is available on the Ministry of Social Development s website www.msd.govt.nz or by phoning 0800 559 009. Home care Nursing care is available at home through district nursing or your local hospital. Your doctor or hospital can arrange this. You may be entitled to assistance with household tasks during your treatment. For information on what help is available contact your hospital social worker or the District Nursing Service at your local hospital. Interpreting services New Zealand s Health and Disability Code states that everyone has the right to have an interpreter present during a medical consultation. Family or friends may assist if you and your doctor do not speak the same language but you can also ask your doctor to provide an interpreter if using family members is inappropriate or not possible. 79 Nutrition wise I changed from week to week. I got to the stage where I didn t like beef anymore. I got into vegetables. I was into wholesome food. Now my cupboards don t have any processed food. Silei What can I do to help myself Many people feel that there is nothing they can do when they are told they have cancer. They feel out of control and helpless for a while. However there are practical ways you can help yourself. He aha ng maimoatanga ka tarea e au He nui ng tngata ka puri rawa atu i te rangona kua pngia rtou i te matepukupuku. Kore rtou e aro ko hea te huringa m rtou. Hunga tr ka taea tonu e koe ng mahi te awhi i a koe an. 80 81 Diet and food safety A balanced nutritious diet will help to keep you as well as possible and cope with any side effects of treatment. The Cancer Society s booklet called Eating Well during Cancer Treatment Kia Pai te Kai i te w Maimoatanga Matepukupuku has useful advice and recipes. Phone your local Cancer Society office for a copy of this booklet phone the cancer information nurses at the Cancer Information Helpline 0800 CANCER (226 237) or view the booklet on our website at www.cancernz.org.nz. The hospital will also have a dietitian who can help. Food safety is of special concern to cancer patients especially during treatment which may suppress immune function. To make food as safe as possible we suggest you follow these guidelines Wash your hands thoroughly before eating. Keep all areas and utensils you use for food preparation clean including washing hands before preparing food and washing fruit and vegetables. Handle raw meat fish poultry and eggs with care and clean carefully any surfaces that have been in contact with these foods. Keep raw meats separate from cooked food. Cook meat poultry and fish well and use pasteurised milk and juices. 82 Refrigerate food quickly to reduce bacterial growth. When eating in restaurants avoid foods that may be contaminated with bacteria such as salad bars sushi and raw or undercooked meats fish poultry and eggs. If there is any concern about the purity of your water (for example if you have well or tank water) have it checked for bacterial content. Te kai tika me te haumaru kai M te kai tika me te kai pai hei whina i a koe ki te noho ora me te rai i ng pnga kino ka whai i ng maimoatanga. Kei roto i te pukapuka Eating Well during Cancer Treatment Kia Pai te Kai i te w Maimoatanga Matepukupuku a Te Khui Matepukupuku o Aotearoa tahi tohutohu whai kiko m te kai me tahi tohutaka. Waea atu ki t Khui Matepukupuku -Rohe m ttahi kape o te pukapuka nei me waea atu rnei ki a Waeawhina Prongo Matepukupuku 0800 CANCER (226 237) m ttahi kape me tikiake i t mtou paetukutuku www.cancernz.org.nz. Kei te hhipera ttahi tohunga m te kai pai hei whina an. He mea nui te haumaru o ng kai m ng troro kei te pngia i te matepukupuku tae atu ki te w o t rtou maimoatanga. Ki te h ng kai tr pea ka tmia ng taunga kauparetanga o te tinana. 83 Exercise Many people find regular exercise helps recovery. Research has shown that people who remain active cope better with their treatment. The problem is that while too much exercise is tiring too little exercise can also make you tired. Therefore it is important to find your own level. Discuss with your doctor or nurse what is best for you. New research shows exercise may be better for your immune system than any other therapy. Recent publications show that maintaining a normal weight and exercising may reduce the risk of breast cancer recurrence. For more information on the benefits of regular physical activity for people with cancer phone the cancer information nurses on the Cancer Information Helpline 0800 CANCER (226 237) or contact your local Cancer Society to receive a copy of our pamphlet Being Active When You Have Cancer. Kori tinana He tokomaha ng tngata e kite ana ka whina te korikori i te hoki an ki te ora. E ai ki ng rangahau ki te rite t korikori tinana ka pai atu koe i te w o te maimoatanga. Ko te raruraru k ahakoa ka pau t hau ki te kaha rawa t kori tinana ka pau r t hau ki te iti rawa korikoringa. N reira he mea nui kia mhio koe he aha te korahi o te kori tinana e pai ana mu. Krero ki t rata ki t nhi rnei m te huarahi pai rawa mu ake. 84 Photographer Nicole Freeman 85 When it was painful I transported myself to the market with fresh fruit at home. I went to songs that have no words that reminded me of home like streams and natural sounds. I imagined myself at moments throughout my lifetime--special places on the beach certain things we did as children. I took myself there. Silei Relaxation techniques Some people find relaxation or meditation helps them to feel better. The hospital social worker nurse or Cancer Society will know whether the hospital runs any relaxation programmes or may be able to advise you on local community programmes. Complementary and alternative therapies Complementary therapy is a term used to describe any treatment or therapy that is not part of the conventional treatment of a disease. It includes things like acupuncture relaxation therapy meditation 86 yoga positive imagery spiritual healing cultural healing art aromatherapy massage. Complementary methods are not given to cure disease but they may help control symptoms and improve wellbeing. Alternative therapy is a term used to describe any treatment or therapy that may be offered as an alternative to mainstream treatments. It includes things like homeopathy naturopathy Chinese herbs. Alternative treatments are sometimes promoted as cancer cures. However they are unproven treatments as they may not have been scientifically tested or if tested they were found to be of little use. They can also be expensive. It is important to let your doctor know if you are taking any complementary or alternative therapies because some treatments may be harmful if they are taken at the same time as conventional treatments. 87 Ng haumanu tpae me tahi atu huarahi haumanu He mea nui te krero ki t rata mn kei te nanao koe i tahi atu haumanu tautoko haumanu whiringa hoki i te mea tr pea ka puta he takakino i tahi maimoatanga ka kawea ngtahitia i te wa o ng maimoatanga. Me whki ki t rata mn kei te nanao koe ki tahi atu maimoatanga aronga whnui. Seeking advice from health professionals If you feel uncomfortable or unsure about your treatment it is important that you discuss any concerns with those involved in your care including your general practitioner (GP). Relationships and sexuality The anxiety and or depression felt by some women after diagnosis or treatment can affect their sexual desire. Sometimes women feel that they are less sexually attractive. Tiredness following an anaesthetic major surgery radiation treatment or chemotherapy will also reduce sexual desire. If you have had a mastectomy looking at yourself in the mirror can be difficult. Sometimes women feel nervous about showing their mastectomy scar to their partners. 88 It helps if you are able to talk openly about your feelings so that your partner understands your fears and concerns. However sometimes partners may be unsure of their own reactions to the breast surgery. While many partners are a great support and may adjust more quickly to the changes than you do others have greater difficulty. They may also feel nervous about their sexual relationship with you. If you are without a partner you may fear you may not be able to have an intimate relationship in the future. You may question how and when you will tell a new partner about your treatment. While some women may quickly begin their usual pattern of love making for others it may take longer. If you and your partner need to make changes it s important to remember that sexual intercourse is only one of the ways that you can express affection for each other. Communicating and sharing your feelings can result in greater openness sensitivity and physical closeness between you both. A gesture of affection gentle touches cuddling and fondling also set your mind at rest about your need for each other. When you feel ready for intercourse you may find some positions more comfortable. If you are on top or on your side there may be less pressure on the affected side. If sexual intercourse is painful because of vaginal dryness special creams such as Sylk or Replens may be useful. 89 Talk to someone you trust if you are experiencing ongoing problems with sexual relationships. Friends family members nurses or your doctor may be able to help. The Cancer Society can also provide information about counsellors who specialise in this area. You may find the Cancer Society s booklet Sexuality and Cancer Hkakatanga me te Matepukupuku helpful. You can get a copy from your local Cancer Society by phoning the cancer information nurses on the Cancer Information Helpline 0800 CANCER (226 237) or by downloading it from our website at www.cancernz.org.nz. Ng hononga me te hkakatanga N te mharahara me te puri ka rongo tahi whine whai muri i te whakataunga mate te maimoatanga rnei ka puta he pnga ki t rtou hiahia onioni. I tahi wa ka whakaaro tahi wahine kua kore rtou e hiahiatia. N te ngenge ka puta i te rehu tokitoki i te hparapara nui i te haumanu iraruke i te hahau ka heke te kaha hiahia onioni. Kore noa iho e roa ka hoki tahi whine ki ng aitanga o mua. M tahi atu whine he roa atu te w katahi an rtou ka tau. Mehemea me huri krua ko t hoa ki te kimi panoni he mea nui ki te mahara ake ehara ko te onioni anake te whakaputanga o te aroha ki waenganui i a krua. M te tuwhera o ng krero me te ngkau ka nui atu t krua aroha t krua piringa. Ko te awhiawhi te mirimiri te p o te ringa ng tohu ki te hhonutanga o ng whakaaro a ttahi ki ttahi. 90 Questions you may wish to ask General questions 1. 2. 3. 4. 5. 6. 7. 8. 9. What type of cancer do I have How extensive is my cancer What stage is it What treatment do you advise for my cancer and why Are there other treatment choices for me What are the risks and possible side effects of each treatment How long will the treatment take I would like to have a second opinion. Can you refer me to someone else It is your right to do so. Is there any cost for treatment If I choose not to have treatment either now or in the future what services are available to help me 10. Is my cancer hereditary 11. Can you suggest any books I can read on breast cancer If you are going to have surgery 12. What will the scar look like 13. Can I have breast reconstruction 14. When can I drive again 15. How much does a prosthesis cost and will I be eligible for a free prosthesis 16. Is there a risk of lymphoedema 91 Seeing the oncologist 17. If I need further treatment what will it be like and when will it begin 18. Will I still be able to have children 19. Will I go through menopause What are the effects of menopause 20. Will the treatment affect my sexual relationships 21. When can I return to work 22. How frequent will my check-ups be and what will they involve If you receive answers you do not understand feel comfortable saying Can you explain that again I am not sure what you mean. or Would you draw a diagram or write it down 92 Ng ptai tr pea ka hiahia koe ki te tuku 1. He aha taku momo matepukupuku 2. Phea te kaha whrahi o taku matepukupuku Kei thea whanga 3. He aha t whakaaro m te maimoatanga me whai au He aha ai i tohungia e koe tnei maimoatanga 4. He maimoatanga atu an hei whiringa mku 5. He aha ng tponotanga mrea me ng putanga ktanga i te taha o tn me tn maimoatanga 6. Ka hia te roa o ng mahi maimoatanga 7. E hiahia ana au ki te whai whakaaro tuarua mai i ttahi atu. Ka taea e koe te tuku i a au ki ttahi atu Kei i a koe te tikanga ki te whai i tnei. 8. He utu an m ng maimoatanga 9. Ki te whakatau au me whai maimoatanga au i nianei a ko ake rnei he aha ng ratonga e wtea ki te whina i a au 10. He mea tuku iho ki a au taku matepukupuku 11. Kei te mhio koe ki tahi pukapuka ka taea e au te pnui e p ana ki te matepukupuku o ng 12. Ka phea te hua o te mtnawe 13. E hei ana au ki te whai hanganga hou m ng 14. hea au hei ki te taraiwa waka an 15. E hia te utu m ttahi prosthesis he mraurau an au m te prosthesis kore utu 16. Ka puta an he mrea m te lymphoedema 93 17. Ki te hoki au ki ng mahi maimoatanga whakamrama mai he aha te hua o aua mahi hei hea ka tmata 18. Ka taea tonu taku whakawhnau tamariki 19. Ka tau mai te koero ki ahau He aha ng putanga i te taha o te koero 20. Ka puta an he pnga ki aku mahi onioni 21. hea au hoki ai ki te mahi 22. Ka phea te auau o ng arowhi i a au he aha ng mahi ka puta. Ki te kore e pai ki a koe ng whakautu ki ptai kaua e mharahara ki te k atu Tn whakamrama mai an Kore au i te mrama ki krero. Tn homai he tauira me tuhi ranei 94 Glossary adjuvant chemotherapy treatment of cancer with drugs to aid or assist another treatment. atypical hyperplasia the milk ducts contain increased numbers of abnormal cells. benign a tumour that is not malignant not cancerous and won t spread to another part of your body. biopsy when the specialists remove a small amount of cells or tissue from your body so that it can then be examined under a microscope. bone scan a picture of the bones that can show cancers other abnormalities such as arthritis and infection. When a mildly radioactive substance is injected cancerous areas in the bone pick up more of the substance than normal bone. cells the building blocks of the body. A human is made of millions of cells which are adapted for different functions. Cells are able to reproduce themselves exactly unless they are abnormal or damaged as are cancer cells. CT scan a scan done with X-rays to create a detailed image of the body and its organs. ducts a small tube in the body. In the breast the milk ducts carry milk from the milk sacs to the nipple. genes a biological unit of DNA able to pass on a single characteristic from parent to offspring. Genes are found in every cell of the body. 95 glands an organ or group of organs that make certain fluids. hormone receptors indicators on the surface of some cancer cells that suggest the cancer depends on hormones to help it grow and it may thus respond to hormone treatment. hormone receptor tests laboratory tests that are done on a sample of tissue to find out whether the cancer is likely to respond to hormone treatment. Hormone blood tests are also done to see if women are post-menopausal. lymph glands or nodes small kidney bean-shaped sacs scattered along the lymphatic system. The lymph nodes filter the lymph fluid to remove bacteria and other harmful agents such as cancer cells. There are lymph nodes throughout your body including in your abdomen neck armpit and groin. lymphoedema swelling caused by a build-up of lymph in the tissues. It is caused by an obstruction of the lymph flow-- usually following surgery or other cancer treatment such as radiation treatment. malignant a tumour that is cancerous and likely to spread if it is not treated. mammogram an X-ray of the breast that can be used to examine a breast lump. Mammograms are also used for women without any breast changes because they may detect a breast cancer before a lump can be felt. mastectomy the surgical removal of the breast. 96 metastasis (plural metastases) a cancer that has grown in a different part of the body because of spread of cancer cells from the original site. For example someone with breast cancer may have metastases in their bones also called secondary cancer. milk sacs the glands in a woman that produce milk. Each breast consists of a number of lobes (divisions) which contain milk sacs where the milk is produced. MRI a scan that uses magnetic resonance to detect abnormalities in the breasts or of other body parts. neo-adjuvant chemotherapy chemotherapy given before surgery to improve the effectiveness of the treatment. ovaries a woman has two ovaries which produce the female sex hormone oestrogen and once a month release an egg (ovum). partial breast irradiation irradiation technique under development covering the site of the (removed) tumour and margin of normal breast given by a number of techniques. primary a malignant tumour starts in one site of the body where it is known as the primary tumour. prosthesis an artificial substitute for a missing part of the body such as a breast. It may help with balance and improve appearance. 97 recurrence when a disease comes back again after what seemed to be a cure. This may be a local recurrence in the original site or be distant metastases. secondary the same as metastasis. sentinel node this is the first lymph node to receive lymphatic drainage (and potentially cancer cells) from a tumour. stereotactic core biopsy a technique that uses three- dimensional X-ray to pinpoint a specific target area. It is used in conjunction with needle biopsy on non-palpable breast abnormalities. tumour a swelling or lump. Tumours can be benign (not cancerous) or malignant (cancerous). ultrasound sound waves of a very high frequency used to examine structures within the body. 98 Suggested reading and websites Book Dr Susan Love s Breast Book Susan M. Love. MD. 5th ed. Da Capo Press Cambridge USA. 2010. For further suggestions phone the cancer information nurses on the Cancer Information Helpline 0800 CANCER (226 237). Websites Cancer Society of New Zealand www.cancernz.org.nz Cancer Australia www.canceraustralia.gov.au. Breast Cancer Care (UK) www.breastcancercare.org.uk The suggested websites not including the Society s are not maintained by the Cancer Society of New Zealand. We only suggest sites we believe offer credible and responsible information but we cannot guarantee that the information on such websites is correct up-to-date or evidence-based medical information. We suggest you discuss any information you find with your cancer care health professionals. This booklet Breast Cancer Te Matepukupuku o ng is part of a series titled Understanding Cancer which is published by the Cancer Society. These booklets and booklets from the Living with Cancer series can be viewed and downloaded from our website www.cancernz.org.nz. 99 Notes You may wish to use this space to write down any questions for or advice given by your doctors nurses or health providers at your next appointment. Tr pea ka pirangi koe ki te whakamahi i tnei whi wtea hei tuhi ptai e hiahia ana koe ki te ptai i t rata ng tapuhi ng kaiwhakarato hauora rnei m t hokinga atu ki te kite an i a rtou. 100 Notes 101 Notes 102 Cancer Society of New Zealand Inc. Te Khui Matepukupuku o Aotearoa National Office PO Box 12700 Wellington 6011 Telephone (04) 494-7270 Auckland Division PO Box 1724 Auckland 1023 Telephone (09) 308-0160 Covering Northland Waikato Bay of Plenty Division PO Box 134 Hamilton 3216 Telephone (07) 838-2027 Covering Tauranga Rotorua Taupo Thames and Waikato Central Districts Division PO Box 5096 Palmerston North 4410 Telephone (06) 364-8989 Covering Taranaki Wanganui Manawatu Hawke s Bay and Gisborne East Coast 103 Wellington Division 52 62 Riddiford Street Wellington 6021 Telephone (04) 389-8421 Covering Marlborough Nelson Wairarapa and Wellington Canterbury West Coast Division PO Box 13450 Christchurch 8011 Telephone (03) 379-5835 Covering South Canterbury West Coast and Ashburton Otago Southland Division PO Box 6258 Dunedin 9016 Telephone (03) 477-7447 Covering Urban and rural Otago and Southland Cancer Information Helpline 0800 CANCER (226 237) www.cancernz.org.nz 104 Feedback Breast Cancer Te Matepukupuku o ng We would like to read what you thought of this booklet whether you found it helpful or not. If you would like to give us your feedback please fill out this questionnaire cut it out and send it to the Information Manager at the address at the bottom of the following page. 1. Did you find this booklet helpful Yes No Please give reason(s) for your answer. 2. Did you find the booklet easy to understand Yes No Please give reason(s) for your answer. 3. Did you have any questions not answered in the booklet Yes No If yes what were they 105 4. What did you like the most about the booklet 5. What did you like the least about the booklet 6. Any other comments Personal information (optional) Are you a person with cancer or a friend relative whnau Gender Female Male Age Ethnicity (please specify) Thank you for helping us review this booklet. The Editorial Team will record your feedback when it arrives and consider it when this booklet is reviewed for its next edition. Please return to The Information Manager Cancer Society of New Zealand PO Box 12700 Wellington 6011. 106 Whakahoki Krero Te Matepukupuku o ng E hiahia ana mtou ki te pnui i u whakaaro e p ana ki te pukapuka nei Mehemea i pai ki a koe ng awhina roto i kore rnei. Mena e prangi ana koe ki te whakahoki krero whakakia tnei rrangi ptai tapahia mai ka tuku mai ki te Kaiwhakahaere Prongo ki te whi tau kei te mutunga o te whrangi ka whai i tnei. 1. He whina i roto i tnei puka e Ko He aha te take i whakautu pnei ai koe 2. I mrama ki a koe ng krero o te puka nei e Ko Homai he krero m te take i whakautu pnei ai koe. 3. He ptai an u kore i whakautua i roto i te puka nei e Ko Mena ai he aha aua ptai 107 4. He aha te mea pai rawa atu o te puka nei 5. He aha ttahi mea koretake rawa e p ana ki te puka nei 6. He krero atu an Prongo Whaiaro (kei i a koe te tikanga ki te whakautu). He tangata whai matepukupuku koe he hoa whanaunga whnau rnei Ira Tangata Wahine T pakeke ( tau) Momo iwi (krerohia mai) Ng mihi nui ki a koe m t arotake i te puka nei. Ka prongohia whakahoki krero ka tae mai ana ka tirohia an i te w ka arotakenga an te puka m tana whakaputanga an. Tn koa whakahokia mai ki Te Kaiwhakahaere Prongo Te Khui Matepukupuku Aotearoa Pouaka Poutpeta 12700 Te Whanganui a Tara 6011. Tne ranei 108 Information support and research research Information support and research Information support and research Information support and The Cancer The Cancer Society New offers informationinformation andservices peopleto peoplecancer cancer The Cancer Society New Zealand Zealand offers information andservices to to peopleto people with The Cancer Society ofZealand offers information and support support services with with cancer Society of of New of New Zealand offers and support support services with cancer and theirandfamilies. families.materials are availableavailablecancers andcancers and treatments. Information and theirand their Printed Printed materials are on specific cancers and treatments. Information families. families.materials are availableavailable on on specific treatments. Information their Printed Printed materials are on specific specific cancers and treatments. Information on on living oncancer with canceralso available. living on livingcanceralso available. available. with living is cancer is is also with with is also available. The Cancer The Cancer major funder offunder of cancer research inZealand. Zealand.research research The Cancer Societyais a majormajor cancer research in New Zealand. Zealand. of ofaim of of research The Cancer Society is aisfunder offunder of cancer research New The aim The research Society is Society a major cancer research in New in New The aim The aim is to determine thethe causes prevention and effective effective treating various types of cancer. cancer. is to determine causes prevention prevention and methods methods treating various of cancer. cancer. is to determine thethe causes and effective effective methods of of various types types of of is to determine causes prevention and methods of of treating treating various types The Society The Society also health promotion through programmes such as those encouraging The Society also undertakes healthhealth promotion through programmesas those those encouraging The Society also undertakes promotion through programmes such such as encouraging also undertakes undertakes health promotion through programmes such as those encouraging SunSmart behaviour eating well eatingphysically active and discouraging smoking.smoking. SunSmart behaviour eatingeatingbeing being physically active and discouraging SunSmart behaviour well well physically active and discouraging smoking.smoking. SunSmart behaviour being well being physically active and discouraging We appreciate your supportsupport We appreciate your your We appreciate supportsupport We appreciate your The Cancer The Cancer Society no directno direct financialfrom Government. Funding Funding comes only The Cancer Society receives directno direct financialfrom Government. Funding Funding comes only The Cancer Society no receives financial support support from Government. comes only Society receives receives financial support support from Government. comes only from donations legacies legacies and bequests. make a donationdonation by phoning 111 through111 through from donations legacies legacies and bequests. make make a bydonation 0900 31 0900 31 111 through from donations and bequests. You can You can a donation phoning by phoning 111 through from donations and bequests. You can You can make a by phoning 0900 31 0900 31 our website our by contacting your local Cancerlocal Cancer Society. our website or by contacting your local Cancer Society. our or website by contacting your local Cancer Society. website or or by contacting your Society. Acknowledgements Acknowledgements Acknowledgements Acknowledgements This booklet has booklet has been for New Zealand from the fromCouncil of Victoria sof Victoria s publication This booklet has been adapted adapted for New Zealand Cancer Council of Victoria s publication This booklet has been for New Zealand from the from thethe Cancer Council Victoria s publication This been adapted adapted for New Zealand Cancer Cancer Council of publication Breast Cancer. TheCancer. The Cancer Society New gratefully acknowledges thethe Council sCouncil s assistance. Breast Cancer. The Cancer Society New Zealand Zealand gratefully acknowledges thethe assistance. Breast Cancer. The Cancer Society ofZealand gratefully acknowledges Council sCouncil s assistance. Breast Cancer Society of of New of New Zealand gratefully acknowledges assistance. The Cancer Society Society wouldto thank for their their reviews and contributions The Cancer Society Society would like thank for reviews advice and contributions The Cancer would like to thank for their reviews advice advice and contributions The Cancer would like like to to thank for their reviews advice and contributions DrDr Birgit Dijkstra Birgit Dijkstra Dijkstra DrDr Birgit Birgit Dijkstra Breast Surgeon Surgeon Department of Surgery Christchurch Hospital Breast Surgeon Surgeon Department Christchurch Hospital Hospital Breast Department of Surgery of Surgery Christchurch Breast Department of Surgery Christchurch Hospital DrDr Carol Johnson Carol Johnson Johnson DrDr Carol Carol Johnson Radiation Oncologist Oncologist Blood and Cancer Centre Hospital Hospital Radiation Oncologist BloodBlood and Cancer Centre Wellington Radiation Oncologist and Cancer Centre Wellington Hospital Hospital Radiation Blood and Cancer Centre Wellington Wellington Professor Professor Bridget Robinson Professor Bridget Robinson Professor Bridget Robinson Bridget Robinson Medical Oncology Service Christchurch Hospital Hospital and School of Medicine in Christchurch Medical Oncology Service Christchurch Hospital Hospital of Medicineof Medicine in Christchurch Medical Oncology Service Christchurch and School and School in Christchurch Medical Oncology Service Christchurch and School of Medicine in Christchurch DrDr David Porter Porter David Porter Porter DrDr David David Medical Oncologist Oncologist Lead Clinician Oncology Breast Team Team Auckland Regional Cancer Medical Oncologist Lead Clinician Medical Medical Oncology Breast Team Auckland Regional Cancer Medical Oncologist Lead Clinician Oncology Breast Team Auckland Regional Cancer Medical Lead Clinician Medical Medical Oncology Breast Auckland Regional Cancer and Blood Services Services and BloodBlood and Services Services and Blood Janice Wood Wood Janice Wood Wood Janice Janice Breat NurseBreat Nurse Specialist DHB BreastDHB BreastAuckland Breat Breat Nurse Specialist Waitemata Breast Service Service Auckland Nurse Specialist Waitemata DHB DHB BreastAuckland Specialist Waitemata Waitemata Service Service Auckland Associate Professor Professor Chris Atkinson Associate Professor ChrisChris Atkinson Associate Professor Atkinson Associate Chris Atkinson Oncologist Oncologist George s Hospital ChristchurchCancer Society of New Zealand s Medical Director Director Oncologist George s Hospital Christchurch and thethe Cancer Society of New Zealand s Medical Director Director Oncologist St St George s Hospital Christchurch and the Cancer Society New Zealand s Medical St St George s Hospital Christchurch and and the Cancer Society of of New Zealand s Medical Meg Biggs Julie Holt Julie Michelle Gundersen-Reid Meg Biggs Julie Julie Holt Michelle Gundersen-Reid Meg Biggs Holt and and Michelle Gundersen-Reid Meg Biggs and Holt and Michelle Gundersen-Reid Cancer Society InformationInformation Nurses Cancer Society Information Nurses Cancer Society Information Nurses Cancer Society Nurses Sarah Stacy-Baynes Sarah Stacy-Baynes Sarah Stacy-Baynes Sarah Stacy-Baynes InformationInformation Manager Information Manager Information Manager Manager WeWe also thank thank thethe women who have experienced cancer reviewed editions and offered many also thank thethe women who have experienced cancer reviewed editions and offered many many WeWe also thank who have experienced cancer reviewedreviewed editions and offered also women women who have experienced cancer editions and offered many valuable valuable suggestions. valuable valuable suggestions. suggestions. suggestions. WeWe also thank thank thethe Cancer Societywho agreed who agreed be photographed for for our booklet. also thank thethe Cancer Society volunteers who agreed be photographed for for our booklet. WeWe also thankSociety volunteers volunteers toagreed photographed our booklet. booklet. also Cancer Cancer Society volunteers who to be to to be photographed our Photography Photography Photography Photography Cancer affects New affects New from all all walks life and all all regions our beautifulbeautiful country.cover cover Cancer affects New Zealanders from walks all all life of life and allof of ourof our country. This cover This cover Cancer affects New Zealanders from of walks and regions all regions of our beautiful country. Cancer Zealanders Zealanders from of walks of life and regions beautiful country. This This photo of photo ofZealand Bush Clematis Clematis flowers (Clematis Paniculata) Puawananga was taken Rob Suisted. photo New Zealand Bush Clematis Clematis flowers (Clematis Paniculata) Puawananga was taken by by Rob Suisted. of photo New Zealand Bush flowers (Clematis Paniculata) Puawananga was taken by Rob Suisted. New of New Zealand Bush flowers (Clematis Paniculata) Puawananga was taken by Rob Suisted. Cancer Society Society Zealand Inc. (2011) (2011) Cancer Society Society Zealand Inc. (2011) (2011) Cancer of New of New Zealand Inc. Cancer of New of New Zealand Inc. All All rightsAll rights reserved.of thisof this publication may be reproduced stored in a retrieval system rightsAll rights reserved.of this publication publication may be reproduced retrieval system reserved. NoNo part No part of this may be reproduced stored in a stored in a retrieval system reserved. part No part publication may be reproduced stored in a retrieval system or transmitted in any formanyby anyor by any means electronic mechanical photocopying recording or transmitted in anyin in anyby anyor by any means mechanical mechanical photocopying recording or transmitted form or form means electronic mechanical photocopying recording or transmitted or form means electronic electronic photocopying recording or otherwise without thethe prior the prior of thethe of thethe publisher. or otherwise without without permission of publisher. or otherwise without the prior permission publisher. or otherwise prior permission permission of publisher. www.cancernz.org.nz ANY QUESTION ANY CANCER 0800 CANCER (226 237) Cancer Information Helpline PI 101