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Breast Cancer


What is cancer?

Cancer is the uncontrolled growth of cells in an organ (such as the breast, cervix, ovary or lung). Cancer cells grow together to form a mass called a tumor. Cancer is life threatening because cancer cells can invade surrounding tissue and spread through the bloodstream or lymphatic system to distant parts of the body (metastasize). Early detection before the cancer spreads provides the best chance of cure.

What is breast cancer?

Breast cancer is the most common type of cancer in women. Men can also develop breast cancer, but it is rare, accounting for less than 1 percent of all cases. Breast tumors, both benign and malignant, can develop in any part of the breast. Most tumors, however, arise from ducts that carry milk from the lobule, where milk is produced, to the nipple. About one in seven adult women in the United States develop breast cancer. If detected at an early stage when the tumor has not spread to lymph nodes, most women, about 97 percent, are cured. Early detection of breast cancer is due mainly to annual mammography screening and physical breast examinations.

The breasts are actually glands that prepare, store and dispense milk.

Each breast is divided into lobules, made up of a tight network of glands, bound together by elastic (connective) tissue that empties into ducts lined by muscle cells. Each area of the breast and each cell type respond differently to hormone changes every month. Some areas soften while other areas become more firm. Knowing this helps to explain why you may feel differences in contour and consistency.

Get to know your breasts

Each month, examine your breasts and develop a familiarity with the usual appearance and feel of your breasts. Since the breast tissue changes with monthly hormone fluctuations, you will notice changes come and go. Most breasts have some areas of “lumpiness” that are perfectly normal. If you have such an area in one breast, check the surrounding area, then the opposite breast. At the same time each month, feel for areas that are different than the surrounding breast tissue and ask yourself:

  • How large is this lumpy area?
  • Is there just one or more than one lump?
  • Did I have this last month?
  • Is there a similar lumpiness on the other breast in the same place?

In addition to lumpiness, look for the following:

  • Dimpling or puckering of the skin anywhere on the breast.
  • Change in skin color or texture or the presence of a rash.
  • Bloody or clear fluid leaking from the nipple.
  • A visible lump.

Detecting Breast Lump

Mammograms

An x-ray of the breast known as a mammogram can detect some cancers that are too small to be felt. However, sometimes lumps that can be felt are not detected in a mammogram. Women of all ages should have their breasts examined every year by a physician or trained health professional.

Much controversy has taken place about when it is best for women to begin getting regular mammograms. Based on recent research data, the National Cancer Institute recommends that:

  • All women in their 40s or older who are at average risk for breast cancer should have screening mammograms every one to two years. (The American Cancer Society suggests annual mammograms.)
  • All women who are at higher risk for breast cancer should ask their doctors about when and how often to schedule screening mammograms.

There are two kinds of mammography:

  • Screening – x-rays that are used to look for breast changes in women who have no signs of breast cancer.
  • Diagnostic – prescribed for women who have unusual breast changes, such as a lump, pain, nipple thickening or discharge, changes in breast size or shape, or who have had a suspicious screening mammogram.

Don’t simply assume that a mammogram is normal if your doctor doesn’t contact you with results. Call and ask.

Clinical Breast Exam

Because some cancers cannot be detected in mammograms, women also should have periodic breast exams by a doctor or nurse. The provider will examine your breasts while you are sitting and while you are lying down.

The provider looks for:

  • Changes in the skin, such as dimpling, scaling or puckering.
  • Nipple discharge or nipple inversion.
  • Difference in size or shape between the two breasts.

Breast Self Examination (BSE)

Women should begin examining their breasts each month beginning around age 20. Doctors are urged to talk with their patients about the limitations of BSE. Research has shown BSE plays a small role in detecting breast cancer compared with mammograms, clinical exams and self-awareness. (Self-awareness is being familiar with how your healthy breasts feel and look like.)

The American Cancer Society (ACS) says evidence does not show monthly BSE has any advantage over annual mammograms and exams by your doctor. The ACS urges you not to substitute BSE for regular mammograms and a doctor’s exam. However, the ACS still says BSE is one way for women to know how their breasts normally feel and to notice any changes. Mammograms continue to be the gold standard in breast cancer detection and can pick up tumors several years before a lump can be felt.

The best time to do BSE is two to three days after completion of the menstrual period. Although the following information provides general guidelines, it’s best to ask your health care provider to show you how to perform BSE to be certain you are doing it correctly.

First, look in the mirror and see if you detect any lumps or thickness, swelling, puckering, dimpling, redness or soreness of the skin, as well as changes in nipple size or shape. Also squeeze the nipple to see if there is any discharge.

Standing upright with one hand behind the head, use the flats of your fingertips to gently feel the breast, making small circles around the nipple, then make larger and larger circles as you work your way around the entire breast. Change and repeat the process on the other breast. Complete the same process while lying down. Also feel the collarbone area and the armpit on each side.

Ultrasound

Ultrasound sends high-frequency sound waves into the breast, creating patterns of echoes that are converted into an image of the breast’s interior (a sonogram). Ultrasound is used to help radiologists evaluate some lumps that can be felt but are hard to see on a mammogram. It distinguishes cysts (fluid filled lesions) from solid masses in the breast. However, unlike mammography, ultrasound cannot detect small tumors. It can help with deciding the extent of breast abnormalities, especially for surgical resection.

Magnetic Resonance Imaging (MRI)

The use of MRI for detecting breast cancer is coming out of the research stage and into clinical practice and is available in selected centers. MRI uses radiowaves and magnets, a special breast coil and a computer to scan the patient to produce its images. Its usefulness in identifying tissues that are abnormally active is being studied. MRI can be helpful in deciding the extent of breast abnormalities, especially for surgical resection. It is also used along with mammography for women with dense breasts and those who are at high risk. It can help tell between a benign and cancerous lump.

Is That Lump Breast Cancer?

Not all lumps in the breast are cancerous. In fact, four-fifths of all breast lumps are not cancer. Some common benign breast changes include:

  • Fibrocystic disease: Generalized breast lumpiness that may become more obvious as a woman approaches middle age and the milk-producing glandular tissue gives way to soft, fatty tissue.
  • Cyclic breast changes: Associated with changes during the menstrual cycle due to extra fluid collecting in the breast cycle. Lumps usually go away by the end of the menstrual period.
  • Cysts: Fluid-filled sacs that often enlarge and become tender just before the menstrual period. This is diagnosed with ultrasound and is usually treated by observation or by fine needle aspiration.
  • Fibroadenomas: Solid, round tumors made up of tissue. They feel rubbery and can be moved around easily. Although they sometimes can be diagnosed with fine needle aspiration, most surgeons believe that it is a good idea to remove fibroadenomas to make sure they are benign.
  • Fat Necrosis: Round, firm lumps formed by damaged and disintegrating fatty tissues, typically occurring in obese women with very large breasts.
  • Sclerosing adenosis: Excessive growth of tissues in the breast’s lobules, frequently causing breast pain. Without a biopsy, adenosis can be difficult to distinguish from cancer.

The only certain way to learn whether a breast lump or abnormality is cancerous is by having a biopsy.

In this procedure, a surgeon removes some of the suspicious breast tissue that is examined under a microscope by a pathologist. There are different forms of biopsy. The doctor determines which technique is best, depending on the nature and location of the lump and the woman’s overall health status.

Biopsy Methods

  • Fine needle aspiration: Uses a very thin needle and syringe to remove either fluid from a cyst or clusters of cells from a solid mass. It can be the first diagnostic technique, depending on the availability of the expert cytologist.
  • Excisional biopsy: Generally used for lumps smaller than an inch in diameter, it removes the entire suspicious area along with a small margin of normal tissue. Usually performed in an outpatient department of a hospital with the use of local anesthesia.
  • Incisional biopsy: Slices a portion of the tumor for the pathologist to examine. Generally used for larger tumors with the use of local anesthesia.
  • Core needle biopsy: Uses a somewhat larger needle with a special cutting edge to remove a small core of tissue. This technique may not work well for lumps that are very hard or very small.
  • Localization biopsy: Uses mammography or ultrasound to locate and a needle or wire to localize the tissue for biopsy (core, excision or FNA). Often used for deeper, non-palpable lumps.
  • Stereotactic localization biopsy: Uses a 3-D X-ray to guide the needle or wire to localize the tissue for biopsy (core, excision or FNA), with a computer plotting the exact position of the suspicious area.

The Pathologist/Cytologist

The pathologist is a specialist who examines cells or tissues under a microscope, looking for abnormal cell shapes and unusual growth patterns. It is important to have a pathologist who is experienced in diagnosing breast cancer evaluate your biopsy slides.

Bring someone along to share the conversation with your doctor and use a tape recorder when you are learning about your biopsy results. If the diagnosis is cancer, you may be too upset to fully take in important information your doctor gives you. Another set of eyes and ears can help. Use the tape recorder to recall and review vital information with family and/or friends if the diagnosis is cancer.

If there is any question about the results of your biopsy, you will want to make sure your biopsy slides have been reviewed by more than one pathologist (second opinion).

Understanding Breast Cancer Staging

t is not uncommon for a woman to hear the word “cancer” and then to completely block out anything the doctor may say after that. No woman can ever be truly prepared to hear that she has cancer.

No matter what type of breast cancer you have, the effect it has on you depends on a number of factors, including your general health. But one of the most important things you can do for yourself is to find others who have already gone through the anxiety of breast cancer to help you through the fear and worry. Now is not the time to withdraw. Learn all you can about breast cancer – knowledge is power.

Understanding the stages of breast cancer

Breast cancer usually is diagnosed as falling into one of five stages. How your cancer is staged and your treatment choices will depend on:

  • How small or large your tumor’s size is and where it is found in your breast
  • If cancer is found in the lymph nodes in your armpit
  • If cancer is found in other parts of your body

Here are some terms sometimes used to describe cancer:

  • Malignant: the biopsy revealed the presence of cancer cells
  • In situ or noninvasive: a very early cancer or precancer that has not spread beyond the breast
  • Invasive: cancer has spread to surrounding tissue in the breast and may have spread to the lymph nodes in the armpit or to other parts of the body
  • Metastasized: the cancer has spread to other parts of the body, such as the bones, lungs, liver or brain

Staging of breast cancer

Stage 0

Very early breast cancer or pre-invasive cancer that has not spread within or outside the breast.

Stage I

Tumor smaller than 2 centimeters (cm) (1 inch). No cancer is found in lymph nodes in the armpit, or outside the breast.

Stage II

Tumor smaller than 2 cm (1 inch). Cancer is found in the lymph nodes in the armpit.

or

Tumor between 2 cm and 5 cm (1 and 2 inches). Cancer may or may not be found in the lymph nodes in the armpit.

or

Tumor larger than 5 cm (2 inches). Cancer is not found in the lymph nodes in the armpit.

Stage III

Tumor smaller than 5 cm (2 inches), with cancer also in the lymph nodes that are stuck together.

or

Tumor larger than 5 cm (2 inches) or cancer is attached to other parts of the breast area including the chest wall, ribs and muscles.

or

Inflammatory breast cancer. In this rare type of cancer, the skin of the breast is red and swollen.

Stage IV

Tumor has spread to other parts of the body, such as the bones, lungs, liver or brain.

Prognosis

Once your doctor has determined the type and stage of breast cancer, your chance of recovery will depend on many factors, including:

  • The type and stage of cancer
  • How fast and how aggressively the cancer is growing
  • How much the breast cancer cells depend on female hormones for growth, measured by hormone receptor tests; tumors that are hormone-dependent (estrogen/progesterone receptor positive) can be treated by hormonal therapy
  • Your age and menopausal status
  • Your general state of health
  • Your mental health and ability to cope with problems

It will be difficult to accept your diagnosis at first, but over time, that may change. A positive attitude and the support of friends and family will not only help you through this ordeal, but may even contribute to your recovery, experts say.

Making decisions

Treatments for breast cancer vary, depending on an individual’s situation. In the past, doctors used to perform biopsies and remove breasts all in the same operation. This rarely happens today. Women need time to absorb biopsy results, learn about their options and perhaps get a second opinion. The advantage of a FNA (fine needle aspiration) gives the patient time to assess her surgical options.

Gone are the days when doctors firmly told patients what was best. Today, patients bear more and more responsibility for speaking with a variety of medical experts, gathering as much information as possible and choosing from several treatment options.

When your doctor tells you that you have breast cancer, you feel overwhelmed with emotions and miss important information. Be sure to bring someone with you and a tape recorder so you can review what your doctor has told you about your disease.

Also, be sure to find others who have already gone through the anxiety of breast cancer to help you through the fear and worry. Now is not the time to withdraw.

Treatment

There are several treatment options. Often, more than one treatment is used.

  • Surgery: taking out the cancer in an operation.
  • Radiation therapy: using high-dose X-rays to kill cancer cells or keep them from dividing and growing.
  • Chemotherapy: using anti-cancer drugs to kill or stop the growth of cancer cells.
  • Hormonal therapy: using hormones to stop cancer cells from growing.
  • Biological therapy (immunotherapy): using the immune system to fight cancer or to lessen the side effects that may be caused by some cancer treatments. Many biological therapies are being tested in clinical trials. See below for more information

Types of surgery

  • Lumpectomy: A surgeon removes the breast cancer, a little normal breast tissue around the lump, and some lymph nodes under the arm. The surgeon is trying to totally remove the cancer, altering the breast as little as possible. Lumpectomy is usually accompanied by radiation therapy to destroy any remaining cancer cells.
  • Total mastectomy: The surgeon removes the entire breast. Some lymph nodes under the arm may be removed also.
  • Partial mastectomy: This surgery conserves as much as the breast as possible. Some breast tissue is removed, as well as the lining over the chest muscles below the tumor and usually some of the lymph nodes under the arm. Radiation therapy usually follows.
  • Modified radical mastectomy: The surgeon removes the breast, some of the lymph nodes under the arm, the lining over the chest muscles and sometimes part of the chest wall muscles.
  • Radical mastectomy: The surgeon removes the breast, chest muscles and all the lymph nodes under the arm. The standard operation for many years, it is used now only rarely when the cancer has spread to the chest muscles. There is no survival advantage if one has local therapy (lumpectomy or partial mastectomy plus radiation treatment versus modified radical mastectomy).
  • A sentinel node biopsy: This is a technique that helps determine if a cancer has spread (metastasized), or is contained locally.

Radiation therapy

High-energy X-rays are used to destroy cancer cells that might still be present in the breast tissue. Doctors sometimes use radiation therapy following a lumpectomy or mastectomy, before or, rarely, instead of surgery and/or in conjunction with chemotherapy. Possible problems: feeling more tired than usual; skin reactions such as itching, redness, soreness, peeling, darkening, or shininess, and decreased sensation, and in some cases problems swallowing. Radiation does NOT cause hair loss, vomiting, or diarrhea. Depending on their risk analysis, women over 70 years of age may not require radiation therapy after surgery.

Chemotherapy

Even when a lump is small, cells may have broken off and spread outside the breast. Doctors can use chemotherapy to destroy them, using either a single drug or a combination of drugs.

The drugs often are injected into the bloodstream through an intravenous needle that is inserted into a vein, but sometimes they are administered as a pill. Adjuvant treatment to reduce the risk of cancer recurrence usually ranges from three to six months. Possible problems: hair loss, loss of appetite, nausea, vomiting, diarrhea, constipation, fatigue, infections, bleeding, weight change, mouth sores and throat soreness, infertility, early menopause, weakening of the heart, reduced ovarian function, damage to ovaries, secondary cancers such as leukemia.

These drugs are also used when the risk for recurrence is high such as having an aggressive (high risk) pathology of your cancer, if the cancer spread to your lymph nodes, and negative estrogen/progestin receptors.

You can learn more about chemotherapy by contacting NCI’s 1-800-4-CANCER (1-800-422-6237) and requesting the following booklets: Helping Yourself During Chemotherapy, Chemotherapy and You, and Eating Hints for Cancer Patients.

Hormonal therapy

If lab tests show that your tumor relied on your natural hormones to grow, any remaining cancer cells may continue to be stimulated by your body’s hormones. Hormonal therapy can prevent your body’s hormones from reaching any remaining cancer cells.

Tamoxifen is one of the most common drugs used for hormonal therapy, taken daily as a pill. Estrogen stimulates the growth of tumors. Tamoxifen combats the resulting stimulation of estrogen receptor positive tumors. Although benefits are generally considered to far outweigh risks, you should be aware that tamoxifen use can increase risks for cancer of the uterus and, rarely, blood clots for patients also undergoing chemotherapy.

Possible problems: hot flashes, nausea, vaginal spotting, increased fertility. Less common side effects include depression, vaginal itching, bleeding or discharge, loss of appetite, eye problems, headache and weight gain.

Arimidex® (aromatase inhibitors) is a drug that may improve survival for women with breast cancer up to 50 percent. Unlike tamoxifen, it prevents estrogen production. It is only effective for postmenopausal women. In a clinical trial, women who were given Arimidex had a 17 percent reduction in the recurrence of the disease. In addition, women who took Arimidex experienced fewer side effects than women who were treated with tamoxifen. Armidex can be used for premenopausal women by giving them Lurpon or Zolodex to stop ovarian function. Femora® and Aromasin®, other aromatase inhibitors, appear to be equivalent to Arimidex and may be superior to tamoxifen for adjuvant and first line therapy.

Biological therapy

Antibodies are proteins made by the body’s own natural immune system that are directed against foreign and infectious agents, called antigens. Monoclonal antibodies engineered through biotechnology are produced as therapeutic drugs to provide specific anti-tumor action within the human body. Herceptin® (trastuzumab) is a monoclonal antibody approved in 1998 by the Food and Drug Administration for the treatment of metastatic breast cancer. It inhibits cancer cell division and growth. Recently, it has been found to improve survival as an adjuvant treatment in patients with HER2-positive breast cancer after surgery.

New treatments designed to repair, stimulate or increase the body’s natural ability to fight breast cancer currently are being investigated in clinical trials worldwide. Some of these experimental immunotherapies utilize, and, in others, boost substances produced naturally by the body’s own cells. Cancer vaccines are being evaluated in clinical trials. Clinical trials adding Avastin® (bevacizumab) to chemotherapy and other VEGFs (vascular endothelial growth factor) have shown promise.

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