If your doctor requests a Breast biopsy

Information about conventional breast cancer treatments - inc surgery, chemo, rads, hormonal, reconstruction, lymphedema, side effects
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sue2211
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Postby sue2211 » Tue Nov 18, 2008 5:59 pm

Fantastic article Nav, especially to those just starting on this journey
sue x
Diagnosed Feb 08. Lumpectomy and 2 sentinel nodes removed - negative. Medullary carcinoma, ER+, PR - , Her2 +.

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Postby gallopinggranny » Mon Nov 17, 2008 8:04 pm

Nav, i wish i had this to read when i was Dxd. Biopsy in itself is a scarey word after a mammogram and i guess that it is normal to feel anxious. luckily the breast screen clinic in Canberra do the biopsy and give you the results in the same day. thanks for posting this important message. :hugs:
Onward and Upward
GG.

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Postby Doxiamonev » Tue Mar 04, 2008 5:56 pm

Annette, this is a great read, Nav emailed this to me when I was "waiting" for my biopsy results. :read: Remember not all biopsys are bad news :hugs:

Thanks Nav for sharing this :hugs:

Doxia
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Some people are always grumbling because roses have thorns; I am thankful that thorns have roses." Alphonse Karr

Dx 27.12.07,Gr 3, IDC Lt breast 1cm (Prim Ca) & 2.5cm (L/Node)
Bilateral Mastectomy & tissue expanders inserted, Axc. clearance 1/17+, Triple Neg.Tx 4 AC chemo,12 wkly Taxol (28/7/08)2 yrs NED!

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If your doctor requests a Breast biopsy

Postby yowyow » Tue Mar 04, 2008 5:32 pm

Women Facing a Breast Biopsy

Introduction: We Know What You’re Going Through

Mary's doctor calls to give her the results of her mammogram. The doctor says, "It's not normal and I think we need to biopsy the area in question." Mary's first thought is, "Could this be breast cancer?"

Another woman, Peg, just found a lump in her breast. She knows that the lump wasn't there last month. Her first thought: "I probably should see the doctor about this, but I'm sure it isn't cancer."

Women react differently to being told that something may be wrong with their breasts. Whatever their feelings and thoughts, at some point these women will want information about their situation.

This information is provided by the American Cancer Society. Women who have had breast lumps, suspicious mammograms, and breast biopsies helped write it. They have gone through something similar to what you may be going through now.

This document offers the basics of benign breast conditions, diagnostic tests (such as different types of biopsies), and breast cancer. It also gives general information on coping with your concerns and fears, and guidance on where to find emotional support. There are many details that we cannot cover here. So in each section, we've added a list of questions that you might want to discuss with your doctor and nurse.

This document is not meant to answer all your questions. It should not take the place of talking with a doctor or nurse.

We will explain many medical terms that you will hear during breast evaluation and diagnosis. As you learn these terms, you will better understand what is being said to you. Knowing these terms will also help you communicate clearly with your health care team. The American Cancer Society has a free Breast Cancer Dictionary that many women and their doctors find very helpful. To request it, call us at 1-800-ACS-2345.

Remember: Just because your doctor wants you to have a biopsy does not mean you have breast cancer. Most breast lumps are not cancer. However, having a biopsy (removal and testing of a suspicious area of the breast) is the only way to know for sure. See a doctor about any changes in your breasts. Even if you do need a biopsy, it is encouraging to know that 4 of every 5 biopsy results are not cancer.

Benign Breast Conditions: Not All Lumps Are Cancer

If you find changes or something unusual in one of your breasts, it is important to see a doctor or nurse as soon as possible. However, please remember that most breast changes are not cancer.

Benign (be-nine) or non-cancerous breast conditions are very common and they are never life threatening. The 2 main types are fibrocystic changes and benign breast tumors.

Fibrocystic Changes

Fibrocystic changes are benign changes in the breast tissue that occur in about half of all women at some time in their lives. This often happens just before a period is about to begin. Although this used to be called "fibrocystic disease," this is not a disease at all. These changes can cause cysts (fluid-filled areas) and areas of lumpiness, thickening, tenderness, nipple discharge, or pain in the breast. If they are painful, cysts can be treated by removing the fluid with a needle and syringe. Lumps and areas of thickening caused by fibrocystic changes are almost always harmless.

Doctors cannot tell from a physical exam alone if a lump is caused by fibrocystic changes. In these cases, doctors will want to do further testing (mammogram or biopsy) to be certain that the suspicious area is not cancer.

If fibrocystic changes are uncomfortable or painful, doctors may suggest that you avoid caffeine or reduce your salt intake. In severe cases, doctors can prescribe medications that may help reduce or relieve the symptoms.

Benign Breast Tumors

Benign breast tumors are non-cancerous areas where breast cells have grown abnormally and rapidly, usually forming a lump. Benign breast tumors are sometimes uncomfortable, but they are not life threatening and cannot spread outside of the breast to other organs. Still, some benign breast conditions such as papillomas and atypical hyperplasia are important to know about because women with these conditions have a higher risk of developing breast cancer. For more information see the American Cancer Society document, Non-cancerous Breast Conditions.

A biopsy (removal and examination of some of the suspicious breast tissue) is required to determine if the tumor is benign or cancerous (see the section "Types of Biopsy Procedures" for more information).

If the benign tumor is large, it may change the breast's size and shape. Depending on the size and number of benign tumors, doctors may or may not recommend excision (removal) by surgery.

If the benign tumor involves the tissue of the milk ducts, it may cause abnormal discharge from the nipple. In some cases, this can be treated by surgery to remove the tumor.

Other Benign Breast Conditions

Mastitis is a breast infection that most often affects women who are breast-feeding. The breast may become red, warm, or painful. Mastitis is treated with antibiotics.

Fat necrosis sometimes results when an injury to the breast heals, leaving scar tissue that can feel like a lump. A biopsy can tell if it is cancer or not. Sometimes when the breast is injured, an oil cyst (fluid-filled area) forms instead of scar tissue during healing. Oil cysts can be diagnosed and treated by aspirating (draining) the fluid inside.

Duct ectasia involves an abnormal milk duct. It is common and most often affects women in their 40s and 50s. The symptoms are usually a green, black, thick, or sticky discharge from the nipple, and tenderness or redness of the nipple and area around the nipple. Duct ectasia can also cause a hard lump, which is usually biopsied to be sure it is not cancer.
Diagnostic Tests for Breast Conditions

Two main tests to diagnose breast conditions are mammograms and ultrasound.

Diagnostic Mammogram

If a woman has noticed breast changes or symptoms, or if a routine screening mammogram has detected a suspicious-looking area, her doctor may arrange for her to get a diagnostic mammogram. During diagnostic mammograms, more x-ray views (pictures) are taken of the breast and extra pictures are focused on the suspicious area.

For a mammogram, the breast is pressed between 2 plates to flatten and spread the tissue. Although this may be uncomfortable for a moment, it is necessary to produce a good, "readable" mammogram. The compression only lasts a few seconds. The entire procedure for a screening mammogram takes about 20 minutes. This procedure produces a black and white image of the breast tissue on a large sheet of film that is read, or interpreted, by a radiologist (a doctor specially trained to read these kinds of tests).

A mammogram cannot prove that an abnormal area is cancer. To confirm whether cancer is present, a small amount of tissue must be removed and examined under a microscope. This procedure is called a biopsy.

You should also be aware that a mammogram is not perfect at finding breast cancer. If you have a breast lump, you should have it checked by your doctor and consider having it biopsied even if your mammogram is normal.

Breast Ultrasound

Breast ultrasound uses sound waves to create a computer image of the inside of the breast. This test is sometimes used to target a specific area of concern that is found on the mammogram or physical exam. Ultrasound is useful for identifying some breast changes, such as those that can be felt but not seen on a mammogram. It also helps distinguish between cysts and solid masses and between benign and cancerous tumors. It is the easiest way to tell if a cyst is present without placing a needle into it to draw out fluid.

Ultrasound, also known as sonography, uses high-frequency sound waves to outline a part of the body. High-frequency sound waves are transmitted into the area of the body being studied and echoed back. These echoes are picked up by the ultrasound probe. A computer changes the sound waves into an image that is displayed on a screen. You are not exposed to radiation during this test.

Magnetic Resonance Imaging (MRI)

MRI is sometimes used after breast cancer has been found. The MRI can show whether lymph nodes are enlarged, which may be a sign that they contain cancer. This can be a clue to the cancer's stage even before surgery. MRI is sometimes used to look for more breast tumors that did not show up on the mammograms. It is also used to help guide the biopsy needle for tumors that can't be seen on mammograms. This is known as MRI-guided biopsy.

Ductogram

Ductograms are sometimes used to determine the cause of nipple discharge. A ductogram, also called a galactogram, involves placing a small amount of fluid into the nipple through a tiny plastic tube. The fluid can be seen on an x-ray, which can then show if there is a mass inside the duct.

Biopsy

While imaging tests like the mammogram and breast ultrasound can locate a suspicious area, they cannot tell whether the area is cancerous. A biopsy is the only way to tell for sure if a benign breast condition or cancer is really present.

Taking a biopsy involves removing some cells from the suspicious area to look at under a microscope. A biopsy can be done using either a needle or surgery to remove part or all of the tumor. The type of biopsy depends on the size and location of the lump or abnormality.

If your doctor thinks you don't need a biopsy, but you feel there's something wrong with your breasts, follow your instincts. Don't be afraid to discuss this with your doctor or go to another doctor for a second opinion.

Second Opinions

Before you have a biopsy, you may want to get a second opinion. This way, another expert from a hospital or mammography facility will read your mammogram. You can ask your doctor to arrange this for you, or you can have the films sent to the expert you have selected.

If you are not being seen at a large cancer center, you can ask your hospital or clinic to help. They should send any previous mammograms and your most recent mammogram to a center that specializes in mammography and diagnosis of breast cancer. Or, if the facility will make copies, you can take them for a second opinion yourself. Be sure to find out ahead of time if the second facility or doctor accepts copies; some facilities read only original x-rays.

It takes great skill and experience to accurately read a mammogram. You want to be sure that your x-ray is being read by an expert.

Types of Biopsy Procedures

Each type of biopsy has its own advantages and disadvantages. The choice of which to use depends on your specific situation. Some of the factors your doctor will consider include how suspicious the tumor appears, how large it is, where in the breast it is located, how many tumors are present, other medical problems you may have, and your personal preferences. You might want to discuss the pros and cons of different biopsy types with your doctor.

Fine Needle Aspiration Biopsy (FNAB)

In an FNA biopsy, the doctor (a pathologist, radiologist, or surgeon) uses a very thin needle attached to a syringe to withdraw (aspirate) a small amount of tissue from a suspicious area. This tissue is then looked at under a microscope. The needle used for FNAB is thinner than the ones used for blood tests.

If the area to be biopsied can be felt, the needle can be guided into the area of the breast change while the doctor is feeling (palpating) it. If the lump can't be felt easily, the doctor might use ultrasound to watch the needle on a screen as it moves toward and into the mass. Or the doctor may use a method called stereotactic needle biopsy to guide the needle. For stereotactic needle biopsy, computers map the exact location of the mass using mammograms taken from 2 angles, which helps the doctor guide the needle to the right spot.

A numbing medicine (local anesthetic) may or may not be used. Because such a thin needle is used for the biopsy, the process of getting the anesthetic may actually be more uncomfortable than the biopsy itself.

Once the needle is in place, fluid is drawn out. If the fluid is clear, the lump is probably a benign cyst. Bloody or cloudy fluid can mean either a benign cyst or, very rarely, a cancer. If the lump is solid, small tissue fragments are drawn out. A pathologist (a doctor specializing in diagnosing disease from tissue samples) will look at the biopsy tissue or fluid under a microscope to find out if it is cancerous.

A fine needle aspiration biopsy can sometimes miss a cancer if the needle is not placed into the area of cancer cells. If it does not provide a clear diagnosis, or your doctor is still suspicious, a second biopsy or a different type of biopsy should be done.

If you are still having menstrual periods (that is, if you are premenopausal), you probably know that "lumpiness" can come and go each month with your menstrual cycle. However, if you have a troublesome lump, the doctor may want to do a FNAB to see if it is a cyst (a fluid-filled sac) or a solid growth (mass or tumor). If an aspiration is performed and the lump goes away after it is drained, it usually means it was a cyst, not cancer. Again, most breast lumps are not cancer.

Core Needle Biopsy (CNB)

A CNB is similar to FNAB. A slightly larger, hollow “core” needle is used to withdraw small cylinders (or "cores") of tissue from the abnormal area in the breast. The procedure is usually done with local anesthesia (you are awake but the breast is numbed) in the doctor's office. The needle is inserted three to six times to get the samples, or "cores." This is more invasive and takes longer than an FNAB, but it is more likely to give a definite result because more tissue is taken to be examined. This procedure can cause some bruising, but usually does not leave internal or external scars.

The doctor performing the FNAB or CNB usually guides the needle into the abnormal area while palpating (feeling) the lump. If the abnormal area is too small to be felt, a radiologist or other doctor may use needle placement, a stereotactic instrument, or ultrasound to guide the needle to the target area.

Stereotactic Core Needle Biopsy

A stereoactic core needle biopsy uses x-ray equipment and a computer to analyze the pictures (x-ray views). The computer then pinpoints exactly where in the abnormal area to place the needle tip. This procedure is often used to biopsy microcalcifications (calcium deposits).

Larger Core Biopsies

Large core biopsies are available that use stereotactic methods to remove even more tissue than a core biopsy. The Mammotome®is a type of vacuum-assisted core biopsy (VACB). For this procedure the skin is numbed and a small incision (about ¼ inch) is made. A hollow probe is inserted through the incision into the abnormal area of breast tissue. A cylinder of tissue is then suctioned in through a hole in the side of the probe, and a rotating knife within the probe cuts the tissue sample from the rest of the breast.

There are 2 other types of vacuum-assisted core biopsy systems:

ATEC
MIBB (short for minimally invasive breast biopsy)
Both of these methods also allow tissue to be removed through a single small opening. And both methods are able to remove more tissue than a standard core biopsy. No stitches are needed and there is minimal scarring. Vacuum-assisted core biopsies are done in outpatient settings.

The ABBI method (short for Advanced Breast Biopsy Instrument) uses a probe with a rotating circular knife and thin heated electrical wire to remove a larger cylinder of abnormal tissue. ABBI is used with x-ray guidance (stereotactic imaging), and can sometimes be used to remove an entire mass or lesion. It is slightly less invasive than a surgical biopsy. It usually requires a few stitches afterward.

In some centers, the biopsy is guided by an MRI, which uses computer analysis to locate the tumor, plot its coordinates, and help to aim the needle or biopsy device into the tumor. This is helpful for women with a suspicious area that can only be seen by MRI. One of the vacuum-assisted core biopsy systems, the ATEC, is designed so that it can be used with an MRI.

Ultrasound-Guided Biopsy

Ultrasound-guided biopsy uses an instrument that emits sound waves and a computer to make images (pictures) of the breast abnormality. A doctor can use this test to guide a needle into very small tumors or cysts.

Surgical Biopsy

Surgical biopsy is used to remove all or part of the lump so it can be looked at under the microscope. An excisional biopsy removes the entire mass or abnormal area, as well as a surrounding margin of normal-appearing breast tissue. In rare circumstances, this type of biopsy can be done in the doctor's office, but it is more commonly done in the hospital's outpatient department under a local anesthesia (where you are awake, but your breast is numb). You may also be given medicine to make you drowsy.

During an excisional breast biopsy the surgeon may use a procedure called wire localization if there is a small lump that is hard to locate by touch or if an area looks suspicious on the x-ray but cannot be felt. After the area is numbed with local anesthetic, a thin, hollow needle is placed into the breast and x-ray views are used to guide the needle to the suspicious area. A thin wire is inserted through the center of the needle. A small hook at the end of the wire keeps it in place. The hollow needle is then removed, and the surgeon uses the wire to guide him to the abnormal area to be removed.

If a benign condition is diagnosed, no further treatment is needed. If the diagnosis is cancer, there is time for you to learn about the disease and to discuss all treatment options with your cancer care team, friends, and family. There is no need to rush into treatment. You may want to get a second opinion before deciding on what treatment is best for you.

Does A Biopsy or Surgery Cause Cancer to Spread?

In nearly all situations, surgery does not cause cancer to spread. There are some important exceptions, such as tumors in the eyes or testicles. Doctors who are experienced in taking biopsies of cancers and treating them with surgery know how to avoid the danger in these situations.

The chances of a needle biopsy causing a cancer to spread are extremely low. In the past, larger needles were used for biopsies, and the chance of spread was higher.

One common myth about cancer is that it will spread if it is exposed to air during surgery. Some people may believe this because they often feel worse after the operation than they did before. It is normal to feel this way when you start to recover from any surgery. And sometimes, no one knows that the cancer has spread until it is seen during surgery. Because of this, some people may link surgery with widespread cancer. However, cancer does not spread because it has been exposed to air. If you delay or refuse surgery because of this myth, then you may be harming yourself by passing up effective treatment.

Surgery and Biopsy: Two Step or One Step?

If you need to have more surgery after a biopsy has shown breast cancer, it is almost always done at a separate time from the biopsy. This is called a two-step procedure. Sometimes, however, it is possible to have a one-step procedure, in which the biopsy and surgery are done at the same time. If you have a one-step procedure, you will want to know all of your treatment options beforehand because you must make important choices before the one-step procedure begins.

The Two-Step Procedure

For many years, a one-step procedure was the only choice. Today, most women and their health care team prefer to schedule further surgery, if needed, at a different time from the biopsy. Many studies have shown that the emotional burden of breast cancer is easier to bear if biopsy and treatment are done at separate times.

In the two-step approach, the biopsy is usually done on an outpatient basis. Local anesthesia is used, so you stay awake. Many women choose local anesthesia plus a sedative through a vein (intravenous or IV). The sedative may make you feel sleepy and soothes any nervous or anxious feelings you may have during the procedure. The biopsy can take about an hour. You can go home an hour or two later, when the sedative wears off.

With the two-step procedure, if the diagnosis is breast cancer, you usually don't have to decide on treatment right away. With most breast cancers, there is no harm to your health in waiting a few weeks. This gives you time to talk about your treatment options with your doctors, family, and friends, and then decide what's best for you. (More information on treatment options is available by calling the American Cancer Society at 1-800-ACS-2345.)

Questions to Ask Before a Biopsy

Here are some questions you might want to ask your doctor before having a biopsy done:


What type of biopsy do you recommend? Why?
How does the size of my breast affect the procedure?
Where will you do the biopsy?
What exactly will you do?
How long will the biopsy take?
Will I be awake or asleep during the biopsy?
Can I drive home afterward or will I need someone to drive me?
If you are using a wire to localize, will you need to check its placement by ultrasound or with a mammogram?
Can you draw me a picture showing the size of the incision and the size of the tissue you will remove?
Will there be a hole there? Will it show afterward?
Where will the scar be? What will it look like?
How soon will I know the results?
Should I call you or will you call me with the results?
Will you or someone else explain the biopsy results to me?
When can I take off the bandage?
When can I take a shower?
Will there be stitches? Will they dissolve or do I need to come back to the office and have them removed?
Will there be bruising or changes in color of the skin?
Will there be a scar?
When can I go back to work? Will I be tired?
Will my activities be limited? Can I lift things? Care for my children?

Your Breast Biopsy Results

After the tissue sample is removed, it is immediately sent to the laboratory where it is examined by a pathologist (a medical doctor who is specially trained to look at cells under a microscope and identify diseases). If your biopsy report comes back negative (or benign), this means that no cancer was found. If there is any question about the results of the biopsy or if for any reason you feel uncomfortable about the results, you may wish to seek a second opinion or pathology review, where another doctor looks at your biopsy tissue. Once you feel comfortable that you do not have cancer, be sure to:


have regular mammograms
continue seeing your health care professional for routine breast exams
be aware of any changes in your breasts, and report changes to your doctor right away
talk with your doctor about your risk of breast cancer

A mammogram may show a lump or other change that can't be felt by a physical exam. Physical exams may find a lump or skin change that a mammogram can't see. If you should ever notice a change in your breasts yourself, let your doctor know right away. Breast changes do not always mean that breast cancer is present. (See Appendix B for more information on finding cancer early.)

If the biopsy indicates that the lump is cancerous, the results will show several important things about the cancer.

Is It In Situ or Invasive?

The biopsy report may say that the cancer is in situ. This means that the cancer started in a milk gland (lobule) or duct (tube that carries milk from the lobule to the nipple) and has not spread to the nearby breast tissue or to other organs in the body.

Invasive or infiltrating cancer means that the tumor started in a lobule or a duct and has spread into nearby breast tissue. This type may spread to the lymph nodes or to other parts of the body through the lymph system and bloodstream.

How Fast Is It Likely to Grow and Spread?

Pathologists look at the appearance and arrangement of the cells to determine the cancer's grade. The grade assigned to the cancer indicates how slowly or quickly the cancer is likely to grow and spread.

Pathologists also use measures called ploidy, cell proliferation rate, Ki-67 tests, and HER2/neu tests to give the medical team a better idea of how quickly or slowly the cancer is likely to grow and spread. These tests help your doctor to choose the best treatment.

Will It Respond to Hormone Therapy?

Estrogen and progesterone receptors are molecules that recognize and respond to the presence of the female hormones estrogen and progesterone. Some breast cancers have these receptors (receptor-positive), and others do not (receptor-negative). Finding out if a cancer has these receptors will help your doctor decide how likely it is to respond to hormonal therapy.

Questions to Ask About Your Biopsy Results

After your biopsy results are back it is important to know if the results are final, definite results or if another biopsy procedure is needed. Here are some questions to ask if they are final results:

If it is not cancer...


Is any follow-up needed?
When should I get my next screening mammogram?

If it is cancer...

Is the cancer in situ or invasive?
If the cancer is in situ, is it a type of cancer that can become invasive?
Does the cancer appear to be growing and/or spreading slowly or quickly?
Is the cancer likely to respond to hormonal therapy?
What types of tests will you recommend to determine the stage of the cancer?
When will I need to start treatment?
More information on breast cancer and its treatment can be found in the American Cancer Society document, Breast Cancer.

Coping: Waiting for the Results

Learning that you might have breast cancer can be very difficult. If you have a biopsy and have to wait for the results, the waiting can be a frightening time during which many women go through some strong emotions, including disbelief, anxiety, fear, anger, and sadness. It is important to know that these feelings are normal. You will need coping strategies to help you find productive ways to deal with the physical and emotional challenges you are facing.

Remember, too, that what works for you may be different from what works for others. Some women find comfort in talking with other people about their breast condition, while others may wish to keep it very private. While some women want to be very involved in their testing decisions, others may wish to place their trust almost entirely in their health care team. The ways in which this event will affect your lifestyle and your body are unique, and your coping strategy will also be unique.

Getting Emotional Support: You Are Not Alone

You will find resources and support -- including your own inner strengths -- that you did not know existed.

If you are married or in a committed relationship, what you are going through will have an impact on that relationship. Waiting for your biopsy test results is a family challenge, as well as a personal one.

Other women who have been through difficulties similar to what you're going through now can be your strongest allies. Talking with them can be very helpful and reassuring. You can reach out – or simply listen – to others who understand your feelings and concerns.

If you learn that your diagnosis is breast cancer, you may find it helpful to talk with someone who has already been through the breast cancer experience. The American Cancer Society's Reach to Recovery Program, available in most communities, is one of many programs that may help you. Reach to Recovery can put you in touch with a woman who has been diagnosed with and treated for breast cancer.

To talk with or receive a visit from a Reach to Recovery volunteer, call your local American Cancer Society office or 1-800-ACS-2345. Also, the Resources section at the end of this document has more information on Reach to Recovery and other resources available to you and your family.

Other Coping Strategies

Here are some other coping strategies you may want to try:

Increase your knowledge. Some women find that learning as much as they can about breast health gives them a sense of control over what happens. If you are interested in more information about breast health or breast cancer, please contact your American Cancer Society. (See the "Resources" section.)

Express your feelings. Most women find that giving some kind of expression to their feelings can help them maintain a positive attitude. You might choose to talk with trusted friends or relatives, keep a private journal, or even dance, sing, paint, or draw to express yourself.

Take care of yourself. Take time to do something you enjoy every day. Prepare your favorite meal, take a bubble bath, go for a walk, meditate, listen to your favorite music, read a good book, or watch a funny movie.

Exercise. If you feel up to it and your doctor agrees that you're ready, start a mild exercise program, perhaps one involving walking, yoga, swimming, or stretching. Exercise can help you feel more in control of your body.

Reach out to others. Widening your circle of friends, whether on your own or through support groups, can help you remember that you are not alone. It also gives you more people with whom to share your fears, hopes, and personal accomplishments. It makes the waiting not so lonely. Talk to a Reach to Recovery volunteer. Interact with one or more support groups in your community.

Additional Resources

More Information From Your American Cancer Society

We have selected some related information that may also be helpful to you. These materials may be ordered from our toll-free number, 1-800-ACS-2345.

After Diagnosis: A Guide
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every day without laughter is a wasted day !!!!



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