Breast Cancer

Breast cancer is a malignant or potentially life-threatening tumor. Not all breast lumps or tumors are malignant. According to the National Women's Health Information Center, most lumps are benign or non-cancerous, although any unusual lump should always be examined by a doctor.

Men can develop breast cancer; however, the disease by far occurs more in women. In fact, it's estimated by the National Institutes of Health (NIH) that one in eight women will develop breast cancer in their lifetime.


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Who's at risk

The American Cancer Society (ACS) and NIH say several factors indicate a woman is at a higher risk of developing breast cancer:

  • Age - The risk of developing breast cancer increases with age. Some 77 percent of new diagnoses of breast cancer each year are in women over the age of 50.
  • Personal medical history - Women with a history of breast cancer in one breast have a three- to four-times higher risk of developing a new cancer in the other breast. Women with a history of benign breast growths are at a higher risk. A previous breast biopsy showing atypical hyperplasia (an irregular pattern of cell growth) also indicates an increased risk of developing breast cancer, as does a diagnosis of lobular carcinoma in situ (LCIS) which is abnormal cells found in the lobules of the breast.
  • Breast density - The National Cancer Institute (NCI) says cancer is more likely to occur in breasts that have a lot of lobular and ductal tissue (that is, dense tissue) than in breasts with a lot of fatty tissue. In addition, when breasts are dense, it is more difficult for doctors to see abnormal areas on a mammogram.
  • Estrogen - According to NCI, evidence suggests that the longer a woman is exposed to estrogen (estrogen made by the body, taken as a drug or delivered by a patch), the more likely she is to develop breast cancer.
  • Radiation exposure - NCI says women whose breasts were exposed to radiation during radiation therapy before age 30, especially those who were treated with radiation for Hodgkin's lymphoma, are at an increased risk for developing breast cancer.
  • Family history - You have a higher risk of developing breast cancer if a close relative has had the disease.
  • Lifestyle - NIH says studies have shown that the use of alcohol may be linked with a higher risk of breast cancer. In addition, some studies have linked obesity with a potentially higher risk. And while the final word is not yet in, still other studies have indicated that a healthy lifestyle, including exercise and a diet low in fat, especially saturated fat, is linked with a reduced rate of breast cancer.
  • Other risk factors - Women who started menstruating at an early age (before age 12), who have had no children or didn't have their first child until after age 30, or who didn't go through menopause until after age 55 have a slightly higher risk of developing breast cancer.

Research also continues into genetic mutations, specifically mutations in the genes BRCA1 and BRCA2, which have been linked to an increased risk of developing both breast and ovarian cancer. NCI says that several different tests for these mutations are available, including tests that look for a known mutation in one of the genes (i.e., a mutation that has already been identified in another family member) and tests that check for all possible mutations in both genes. DNA is needed for mutation testing. Genetic counseling is generally recommended before and after any genetic test for an inherited cancer syndrome. This counseling should be performed by a healthcare professional who is experienced in cancer genetics.

Know your breasts

ACS says that evidence is lacking about the benefit of physical breast exams done by either a health professional or by yourself for breast cancer screening. But you should ask your doctor or healthcare provider what is right for you. A clinical breast examination is a breast examination performed by a doctor, physician's assistant or nurse practitioner. During this exam, the healthcare provider will talk with you about any potential symptoms, examine your breasts visually and check the condition of the skin, examine the nipples for any issues such as discharge, and then palpate or feel the deeper tissue of each breast, as well as the armpit area.

Breast self-examination is another way to discover abnormalities. The American College of Obstetricians and Gynecologists (ACOG) says you should know what is normal for your breasts. If you feel any abnormalities in your breasts, or if there are any changes, see your healthcare provider as soon as possible. But don't panic; keep in mind that most lumps in the breast are not cancer, although any lump should always be examined by a qualified physician at once.

Mammograms

ACOG says mammograms can detect breast abnormalities before you can actually feel them. Although different organizations have offered different advice on the exact timetables for mammograms, mammograms remain one of the most effective tools for detecting breast cancer in its earliest, most treatable stage.

There are different ways mammograms are used:

  • Screening mammograms - Screening mammograms are done on a regular basis, compared to your previous mammogram, and used to check for potential abnormalities.
  • Diagnostic mammograms - A diagnostic mammogram is done when you or your doctor detect a suspicious lump or other problem.

Currently, the U.S. Preventive Services Task Force (USPSTF) says the strongest evidence of mammography's benefit and reduced mortality from breast cancer is among women ages 50-74. USPSTF also says there are some risks associated with mammography (false-positive results that lead to unnecessary biopsies or surgery), but that these risks lessen as women get older. ACS recommends women be given the option of yearly mammograms starting at age 40 and women age 45 to 54 should get mammograms every year. At age 55, ACS recommends that women can switch to every other year if they choose. Screenings are recommended to continue as long as a woman is in good health and has a continued life expectancy of at least 10 years. Special circumstances - such as a family history of breast cancer - may indicate a need for earlier mammograms. Each woman should discuss her personal needs with her doctor or healthcare provider.

When you go for a mammogram, you will stand in front of a special x-ray machine. The person who takes the x-rays, called a radiologic technologist, places your breasts (one at a time) between two plastic plates. During a mammogram, the breast is compressed, in order to produce a clear x-ray. Some women find this procedure less uncomfortable if they schedule a mammogram right after their period, when the breasts are less tender. Often, two pictures are taken of each breast - one from the side and one from above. Options include:

  • Traditional mammography - In traditional mammography, the x-rays are manually reviewed by a radiologist.
  • Computer aided detection (CAD) - In computer aided mammography or computer aided detection, a computer program is used to evaluate the mammogram as well, to find areas that might require additional review.
  • Digital mammography - Digital mammography uses a computer to collect and display the x-ray images. This allows the technician to contrast different areas and highlight potential problems. Digital mammography can be helpful in women with dense breast tissue. Digital mammography also allows for 3D imaging.
  • 3D mammography - In 3D mammography, multiple digital images of the breast are taken from different angles. The images are converted into a stack of very thin layers or slices. These layers or slices can be viewed individually or they can be combined to create a three-dimensional image. Computer software is used to create the 3D image from the slices. From the patient's point of view, the experience is comparable to traditional mammography.

ACS says you shouldn't wear deodorant, cream or powder under your arms when you get a mammogram, as they can interfere with the quality of the mammogram. If you have breast implants, be sure to tell your mammography facility that you have them when you make your appointment.

Mammograms allow the doctor to have a closer look for breast lumps and changes in breast tissue. Mammograms can show small lumps or growths that a doctor or woman may not be able to feel when doing a breast exam. When reading a mammogram, doctors look for abnormalities, as well as changes from previous mammograms.

Other tests

There are other scanning tests that can be used for cancer detection.

Magnetic resonance imaging - Magnetic resonance imaging (MRI) uses radio waves and strong magnets instead of x-rays.The energy from the radio waves is absorbed and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a very detailed image. MRI can be used along with mammograms for screening women who have a high risk of developing breast cancer, or it can be used to better examine suspicious areas found by a mammogram.

Ultrasound - Ultrasound uses sound waves to outline a part of the body. Ultrasound can help distinguish between cysts (fluid-filled sacs) and solid masses. In someone with a breast tumor, it can also be used to look for enlarged lymph nodes under the arm.

Women should discuss their risks with their healthcare provider.

Diagnosis and classification

Each breast has 15 to 20 sections called lobes. Within each lobe are many smaller lobules. Lobules end in dozens of tiny bulbs that can produce milk. The lobes, lobules and bulbs are all linked by thin tubes called ducts. These ducts lead to the nipple in the center of a dark area of skin called the areola. Abnormal cell growth can start in any of these areas.

  • Ductal carcinoma - NCI says the most common type of breast cancer is ductal carcinoma. It begins in the lining of the ducts.
    • Invasive ductal carcinoma (IDC) - In IDC, cancer started in the ducts, then invaded surrounding tissue and, in some cases, has spread beyond the breasts. IDC is the most common invasive breast cancer.
    • Ductal carcinoma in situ (DCIS) - DCIS refers to ductal cancer that has not invaded the surrounding breast tissue. This is early-stage breast cancer, and is sometimes considered pre-cancer, although it can develop into invasive breast cancer if not treated.
  • Lobular carcinoma - Lobular carcinoma arises in the lobules.
    • Invasive lobular carcinoma (ILC) - In ILC, cancer started in the lobules, then invaded surrounding tissue and, in some cases, has spread beyond the breasts.
    • Lobular carcinoma in situ (LCIS) or lobular neoplasia - LCIS or lobular neoplasia refers to the growth of abnormal cells in the lobules that have not spread to the surrounding tissue. Although the term LCIS includes the word "carcinoma," LCIS is not breast cancer. However, it can increase a woman's risk of developing cancer in either breast. Women diagnosed with LCIS should discuss screening guidelines with their healthcare provider.

There are other, less common diagnoses. Inflammatory breast cancer is a rare type of late-stage breast cancer in which the breast looks red and swollen because cancer cells block the lymph vessels in the skin of the breast. Symptoms of inflammatory breast cancer include a sudden increase in breast size, itching, dimpling, thickening of the skin, and the breast may feel warm to the touch. Another less common type of cancer, called Paget's disease of breast, is a slowly growing cancer that starts in the milk ducts of the nipple. Symptoms of Paget's disease of breast include a rash, inflammation, crusting or bleeding, discharge, nipple inversion. These symptoms can also indicate a benign condition, but if you have any unusual symptoms, see your doctor at once.

Tests and staging

If an abnormal area shows up on your mammogram, you may need to have more x-rays. You also may need a biopsy. A biopsy is the only way to tell for sure if cancer is present. In a biopsy, a sample of tissue can be taken for examination under a microscope, in order to determine if there is any cancer present. NCI says imaging techniques play an important role in biopsy. One type of needle biopsy, the stereotactic-guided biopsy, uses a computer and scanning devices to pinpoint the precise location of the abnormal area. A needle is then inserted into the breast and a tissue sample is obtained.

It is important to know the stage in order to plan the best treatment. The following stages are used, according to NCI:

  • Stage 0 (carcinoma in situ)There are 3 types of breast carcinoma in situ:
    • Ductal carcinoma in situ (DCIS) is a very early breast cancer that may develop into an invasive type of breast cancer (cancer that has spread from the duct into surrounding tissues).
    • Lobular carcinoma in situ (LCIS) is not cancer, but rather a marker or indicator that identifies a woman as having an increased risk of developing breast cancer.
    • Paget disease of the nipple is a condition in which abnormal cells are found in the nipple only.
  • Stage IIn stage I, the cancer is no larger than 2 centimeters (about 1 inch) and has not spread outside the breast.
  • Stage IIAIn stage IIA, the cancer is either:
    • no larger than 2 centimeters (about 1 inch) but has spread to the axillary lymph nodes (the lymph nodes under the arm); or
    • between 2 and 5 centimeters (1 to 2 inches) but has not spread to the axillary lymph nodes
  • Stage IIB In stage IIB, the cancer is either:
    • between 2 and 5 centimeters (1 to 2 inches) and has spread to the axillary lymph nodes (the lymph nodes under the arm); or
    • larger than 5 centimeters (about 2 inches) but has not spread to the axillary lymph nodes
  • Stage IIIAIn stage IIIA, the cancer is either:
    • no tumor is found in the breast or the tumor may be any size. Cancer is found in 4 to 9 axillary lymph nodes or in the lymph nodes near the breastbone (found during imaging tests or a physical exam); or
    • the tumor is larger than 5 centimeters. Small clusters of breast cancer cells (larger than 0.2 millimeter but not larger than 2 millimeters) are found in the lymph nodes; or
    • the tumor is larger than 5 centimeters. Cancer has spread to 1 to 3 axillary lymph nodes or to the lymph nodes near the breastbone (found during a sentinel lymph node biopsy).
  • Stage IIIBIn stage IIIB, the cancer has either:
    • spread to tissues near the breast (the skin or chest wall, including the ribs and muscles in the chest); or
    • spread to lymph nodes inside the chest wall along the breastbone
  • Stage IIICIn stage IIIC, no tumor is found in the breast or the tumor may be any size. Cancer may have spread to the skin of the breast and caused swelling or an ulcer and/or has spread to the chest wall.
  • Stage IVIn stage IV, the cancer has spread to other organs of the body, most often the bones, lungs, liver, or brain;

Treatments

If cancer is present, treatment will depend on where the cancer is and whether it is invasive or has spread to nearby tissue. There are two basic types of treatment for breast cancer, local and systemic. NCI says you can have one or both types of treatment.

Local treatments are used to remove or destroy breast cancer in a specific area. NCI says surgery is the main local therapy for breast cancer. Surgical options include:

  • Mastectomy - An operation to remove the breast (or as much of the breast tissue as possible) is a mastectomy. In total (simple) mastectomy, the surgeon removes the whole breast. Some lymph nodes under the arm may also be removed. In modified radical mastectomy, the surgeon removes the whole breast, and most or all of the lymph nodes under the arm. Often, the lining over the chest muscles is removed. A woman may choose to have breast reconstruction if she has a mastectomy. This is plastic surgery to rebuild the shape of the breast. It may be done at the same time as a mastectomy or later. If you are considering reconstruction, you may wish to talk with a plastic surgeon before having a mastectomy.
  • Breast-conserving surgery - This type of surgery includes:
    • lumpectomy
    • partial mastectomy
    • segmental mastectomy
    • quadrantectomy
    Breast-conserving surgeries remove the cancer but leave most of the breast intact. In a lumpectomy, the surgeon removes the cancer and some normal breast tissue surrounding the lump in order to obtain "margins" around the tumor that are free of cancer. Radiation therapy is commonly used together with lumpectomy, in order to further reduce the risk of recurrence. The radiation may come from an external source. Brachytherapy is another type of radiation therapy in which the radiation source is placed inside the breast. You would need to discuss all your options with your healthcare provider.The other types of breast-conserving surgery remove a somewhat larger area of the healthy breast. The appearance of the breast will depend on the size of the breast compared to the size of the cancer and the amount of healthy breast tissue that is removed.The appearance of the scar depends on the type of surgery and the location of the cancer.

During surgery, some of the lymph nodes (small bean-shaped organs that are part of the immune system may also be removed. This will be done to determine if the cancer has spread.

A doctor may recommend radiation as well, especially after breast-conserving surgery, to destroy any breast cancer cells that may remain in the area. Radiation therapy is treatment with high-energy rays or particles that destroy cancer cells. ACS says the radiation can be focused from a source outside the body on the area affected by the cancer, including the breast, chest wall, and/or underarm area. Internal radiation, or brachytherapy, is another way to deliver radiation therapy. In this therapy, radioactive seeds or pellets are placed directly into the breast tissue next to the cancer. You should discuss all the options with your doctor and consider obtaining a second opinion before making a final decision.

Systemic treatments affect cells throughout the body. Systemic treatments can be used to shrink a tumor before local therapy, they can be used after other treatments to prevent reoccurrence or they can be used to treat cancer that has spread. Examples of systemic therapy include chemotherapy, hormonal therapy and biological therapy. Chemotherapy for breast cancer is usually a combination of drugs, according to NCI. The drugs may be given in a pill or by injection. Biological therapy is a treatment designed to enhance the body's natural defenses against cancer.

Hormonal therapy may be used if tests show that hormones are helping the cancer to grow. An estrogen receptor, found on some cancer cells, is a protein to which estrogen binds. Cancer cells with this protein are considered ER-positive, and breast cancer cells that are ER-positive require the hormone estrogen to grow. These cancer cells will usually respond to hormone (antiestrogen) therapy that blocks these receptor sites. Selective estrogen receptor modulators (such as tamoxifen and raloxifene) are examples of a class of drugs that help prevent estrogen from binding to these receptors. Aromatase inhibitors (such as anastrozole and letrozole) are examples of classes of drugs that can block the production of estrogen. Conversely, breast cancer cells that do not have a protein or receptor molecule, to which estrogen will attach, are called ER-negative cells. These cells do not need the hormone estrogen to grow and usually do not respond to antiestrogen therapy. Hormonal therapy deprives the cancer cells of estrogen. Examples include surgery to remove the ovaries, and drugs. NCI says some drugs can reduce the risk of breast cancer, but also have potentially serious side effects such as endometrial cancer and blood clots in major veins. There are also targeted drugs, which attack specific abnormalities within cancer cells. Some of these drugs, such as trastuzumab, target a protein called HER2 that can help breast cancer cells grow. Another targeted drug, bevacizumab, inhibits the growth of new blood vessels, which may fuel cancer cells.

Someone with breast cancer may also develop a condition called hypercalcemia - too much calcium in the blood - which in turn can cause loss of appetite, nausea, thirst, fatigue, muscle weakness, restlessness and confusion. This can often require medication and rehydration. The type of treatment will vary for every woman. It will depend on many factors including, but not limited to:

  • age
  • general health
  • size and location of the tumor
  • type of cancer
  • size of the breast

One of the most important considerations in treatment is the size of the tumor and if the cancer has spread - once again a good reason for early detection.

All Concept Communications material is provided for information only and is neither advice nor a substitute for proper medical care. Consult a qualified healthcare professional who understands your particular history for individual concerns.
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