Disease: Breast Cancer

    Breast cancer facts

    • Breast cancer is the most common cancer among American women.
    • One in every eight women in the United States develops breast cancer.
    • There are many types of breast cancer that differ in their capability of spreading (metastasize) to other body tissues.
    • The causes of breast cancer are not yet fully known, although a number of risk factors have been identified.
    • There are many different types of breast cancer.
    • Breast cancer symptoms and signs include
      • a lump in the breast or armpit,
      • nipple discharge,
      • nipple retraction,
      • orange-peel appearance or dimpling of the breast's skin,
      • breast pain,
      • swollen lymph nodes in the neck or armpit,
      • change in the size or shape of the breast.
    • Breast cancer is diagnosed during a physical exam, by self-examination of the breasts, mammography, ultrasound testing, and biopsy.
    • Treatment of breast cancer depends on the type of cancer and its stage (the extent of spread in the body).

    According to the American Cancer society:

    • over 200,000 new cases of invasive breast cancer are diagnosed each year in women and over 2,000 in men;
    • approximately 40,000 women and 400 men died of breast cancer in 2011;
    • there are over 2.5 million breast cancer survivors in the United States;
    • although breast cancer survival and awareness has increased significantly in the United States for all races, several studies have cited a significantly worse survival rate for African-American women compared to white women;
    • guidelines for mammography differ depending on the organization making recommendations. Currently, the American Cancer Society recommends yearly mammograms starting at age 40 for women at average risk for breast cancer.

    What is breast cancer?

    Breast cancer is a malignant tumor (a collection of cancer cells) arising from the cells of the breast. Although breast cancer predominantly occurs in women, it can also affect men. This article deals with breast cancer in women.

    Picture of the anatomy of the breast

    What are the different types of breast cancer?

    There are many types of breast cancer. Some are more common than others, and there are also combinations of cancers. Some of the most common types of cancer are as follows:

    Ductal carcinoma in situ: The most common type of noninvasive breast cancer is ductal carcinoma in situ (DCIS). This type of cancer has not spread and therefore usually has a very high cure rate.

    Invasive ductal carcinoma: This cancer starts in a duct of the breast and grows into the surrounding tissue. It is the most common form of breast cancer. About 80% of invasive breast cancers are invasive ductal carcinoma.

    Invasive lobular carcinoma: This breast cancer starts in the glands of the breast that produce milk. Approximately 10% of invasive breast cancers are invasive lobular carcinoma.

    The remainder of breast cancers are much less common and include the following:

    Mucinous carcinoma are formed from mucus-producing cancer cells. Mixed tumors contain a variety of cell types. Medullary carcinoma is an infiltrating breast cancer that presents with well-defined boundaries between the cancerous and noncancerous tissue.

    Inflammatory breast cancer: This cancer makes the skin of the breast appear red and feel warm (giving it the appearance of an infection). These changes are due to the blockage of lymph vessels by cancer cells.

    Triple-negative breast cancers: This is a subtype of invasive cancer with cells that lack estrogen and progesterone receptors and have no excess of a specific protein (HER2) on their surface. It tends to appear more often in younger women and African-American women.

    Paget's disease of the nipple: This cancer starts in the ducts of the breast and spreads to the nipple and the area surrounding the nipple. It usually presents with crusting and redness around the nipple.

    Adenoid cystic carcinoma: These cancers have both glandular and cystic features. They tend not to spread aggressively and have a good prognosis.

    The following are other uncommon types of breast cancer:

    • Papillary carcinoma
    • Phyllodes tumor
    • Angiosarcoma
    • Tubular carcinoma

    What are the statistics on male breast cancer?

    Breast cancer is rare in men (approximately 2,000 new cases diagnosed per year in the U.S.) but typically has a significantly worse outcome. This is partially related to the often late diagnosis of male breast cancer, when the cancer has already spread.

    Symptoms are similar to the symptoms in women, with the most common symptom being a lump or change in skin of the breast tissue or nipple discharge. Although it can occur at any age, male breast cancer usually occurs in men over 60.

    What causes breast cancer?

    There are many risk factors that increase the chance of developing breast cancer. Although we know some of these risk factors, we don't know how these factors cause the development of a cancer cell.

    What are breast cancer risk factors?

    Some of the breast cancer risk factors can be modified (such as alcohol use) while others cannot be influenced (such as age). It is important to discuss these risks with a health-care provider anytime new therapies are started (for example, postmenopausal hormone therapy).

    The following are risk factors for breast cancer:

    • Age: The chances of breast cancer increase as one gets older.
    • Family history: The risk of breast cancer is higher among women who have relatives with the disease. Having a close relative with the disease (sister, mother, daughter) doubles a woman's risk.
    • Personal history: Having been diagnosed with breast cancer in one breast increases the risk of cancer in the other breast or the chance of an additional cancer in the original breast.
    • Women diagnosed with certain benign breast conditions have an increased risk of breast cancer. These include atypical hyperplasia, a condition in which there is abnormal proliferation of breast cells but no cancer has developed.
    • Menstruation: Women who started their menstrual cycle at a younger age (before 12) or went through menopause later (after 55) have a slightly increased risk.
    • Breast tissue: Women with dense breast tissue (as documented by mammogram) have a higher risk of breast cancer.
    • Race: White women have a higher risk of developing breast cancer, but African-American women tend to have more aggressive tumors when they do develop breast cancer.
    • Exposure to previous chest radiation or use of diethylstilbestrol increases the risk of breast cancer.
    • Having no children or the first child after age 30 increases the risk of breast cancer.
    • Breastfeeding for one and a half to two years might slightly lower the risk of breast cancer.
    • Being overweight or obese increases the risk of breast cancer.
    • Use of oral contraceptives in the last 10 years increases the risk of breast cancer.
    • Using combined hormone therapy after menopause increases the risk of breast cancer.
    • Alcohol use increases the risk of breast cancer, and this seems to be proportional to the amount of alcohol used.
    • Exercise seems to lower the risk of breast cancer.
    • Genetic risk factors: The most common causes are mutations in the BRCA1 and BRCA2 genes. Inheriting a mutated gene from a parent means that one has a significantly higher risk of developing breast cancer.

    How is breast cancer staging determined?

    Staging is the process of determining the extent of the cancer and its spread in the body. Together with the type of cancer, staging is used to determine the appropriate therapy and to predict chances for survival.

    To determine if the cancer has spread, several different imaging techniques can be used.

    Chest X-ray: It looks for spread of the cancer to the lung.

    Mammograms: More detailed and additional mammograms provide more images of the breast and may locate other abnormalities.

    Computerized tomography (CT scan): These specialized X-rays are used to look at different parts of your body to determine if the breast cancer has spread. It could include a CT of the brain, lungs, or any other area of concern.

    Bone scan: A bone scan determines if the cancer has spread (metastasized) to the bones. Low level radioactive material is injected into the bloodstream, and over a few hours, images are taken to determine if there is uptake in certain bone areas, indicating metastasis.

    Positron emission tomography (PET scan): A radioactive material is injected that is absorbed preferentially by rapidly growing cells (such as cancer cells). The PET scanner then locates these areas in your body.

    Staging system

    This system is used by a health-care team to summarize in a standard way the extent and spread of the cancer. This staging can then be used to determine the treatment most appropriate for the type of cancer.

    The most widely used system in the U.S. is the American Joint Committee on Cancer TNM system.

    Besides the information gained from the imaging tests, this system also uses the results from surgical procedures. After surgery, a pathologist looks at the cells from the breast cancer as well as from the lymph nodes. This information gained is incorporated into the staging as it tends to be more accurate than the physical exam and X-ray findings alone.

    TNM staging. This system uses letters and numbers to describe certain tumor characteristics in a uniform manner. This allows health-care providers to stage the cancer (which helps determine the most appropriate therapy) and aids communication among health-care providers.

    T: describes the size of the tumor. It is followed by a number from 0 to 4. Higher numbers indicate a larger tumor or greater spread:

    TX: Primary tumor cannot be assessed
    T0: No evidence of primary tumor
    Tis: Carcinoma in situ
    T1: Tumor is 2 cm or less across
    T2: Tumor is 2 cm-5 cm
    T3: Tumor is more than 5 cm
    T4: Tumor of any size growing into the chest wall or skin.

    N: describes the spread to lymph node near the breast. It is followed by a number from 0 to 3.

    NX: Nearby lymph nodes cannot be assessed (for example if they have previously been removed).
    N0: There has been no spread to nearby lymph nodes. In addition to the numbers, this part of the staging is modified by the designation "i+" if the cancer cells are only seen by immunohistochemistry (a special stain) and "mol+" if the cancer could only be found using PCR (special detection technique to detect cancer at the molecular level).
    N1: Cancer has spread to one to three axillary lymph nodes (underarm lymph nodes) or tiny amounts of cancer are found in internal mammary lymph nodes (lymph nodes near breastbone).
    N2: Cancer has spread to four to nine axillary lymph nodes or the cancer has enlarged the internal mammary lymph nodes.
    N3: Any of the conditions below

    • Cancer has spread to 10 or more axillary lymph nodes with at least one cancer spread larger than 2 mm.
    • Cancer has spread to lymph nodes under the clavicle with at least area of cancer spread greater than 2 mm.

    M: This letter is followed by a 0 or 1, indicating whether the cancer has spread to other organs.

    MX: Metastasis cannot be assessed.
    M0: No distant spread is found on imaging procedures or by physical exam.
    M1: Spread to other organs is present.

    Once the T, N, and M categories have been determined, they are combined into staging groups. There are five major staging groups, stage 0 to stage IV, which are subdivided into A and B, or A and B and C, depending on the underlying cancer and the T, N, and M scale.

    Cancers with similar stages often require similar treatments.

    What is the prognosis of breast cancer?

    Survival rates are a way for health-care professionals to discuss the prognosis and outlook of a cancer diagnosis with their patients. Patients have to determine if they want to know this number or not and should let their health-care providers know.

    The number most frequently discussed is five-year survival. It is the percentage of patients who live at least five years after they are diagnosed with cancer. Many of these patients live much longer, and some patients die earlier from causes other than breast cancer. With a constant change in therapies, these numbers also change. The current five-year survival statistic is based on patients who were diagnosed at least five years ago and may have received different therapies than are available today.

    All of this needs to be taken into consideration when interpreting these numbers for oneself.

    Below are the statistics from the National Cancer Institute's SEER database.

    StageFive-year survival rate0100%I100%II93%III72%IV22%

    These statistics are for all patients diagnosed and reported. Several recent studies have looked at different racial survival statistics and have found a higher mortality (death rate) in African-American women compared to white women in the same geographic area.

    What is the treatment for breast cancer?

    Patients with breast cancer have many treatment options. Most treatments are adjusted specifically to the type of cancer and the staging group. Treatment options should be discussed with a health-care team. The following are the basic treatment modalities used in the treatment of breast cancer.

    Surgery

    Most women with breast cancer will require surgery. Broadly, the surgical therapies for breast cancer can be divided into breast-conserving surgery and mastectomy.

    Breast-conserving surgery

    This surgery will only remove part of the breast (sometimes referred to as partial mastectomy). The extent of the surgery is determined by the size and location of the tumor.

    In a lumpectomy, only the breast lump and some surrounding tissue is removed. The surrounding tissue (margins) are inspected for cancer cells. If no cancer cells are found, this is called "negative" or "clear margins." Frequently, radiation therapy is given after lumpectomies.

    Mastectomy

    During a mastectomy (sometimes also referred to as a simple mastectomy), all the breast tissue is removed. If immediate reconstruction is considered, a skin-sparing mastectomy is sometimes performed. In this surgery, all the breast tissue is removed as well but the overlying skin is preserved.

    Radical mastectomy

    During this surgery, the surgeon removes the axillary lymph nodes as well as the chest wall muscle in addition to the breast. This procedure is done much less frequently than in the past, as in most cases, a modified radical mastectomy is as effective.

    Modified radical mastectomy

    This surgery removes the axillary lymph nodes in addition to the breast tissue. Depending on the stage of the cancer, a health-care team might give someone a choice between a lumpectomy and a mastectomy. Lumpectomy allows sparing of the breast but usually requires radiation therapy afterward. If lumpectomy is indicated, long-term follow-up shows no advantage of a mastectomy over the lumpectomy.

    Preventive surgery

    For a small group of patients who have a very high risk of breast cancer, surgery to remove the breasts may be an option. Although this reduces the risk significantly, a small chance of developing cancer remains.

    Double mastectomy is a surgical option to prevent breast cancer. This prophylactic (preventive) surgery can decrease the risk of breast cancer by about 90% for women at moderate to high risk for breast cancer.

    Such an approach should be carefully discussed with a health-care team.

    The discussion about whether to undergo any preventive surgery should include

    • genetic testing for BRCA1 or BRCA2 gene mutations,
    • full review of risk factors,
    • family history of cancer and specifically breast cancer,
    • other preventive options such as medications.
    Radiation therapy

    Radiation therapy destroys cancer cells with high energy rays. There are two ways to administer radiation therapy.

    External beam radiation

    This is the usual way radiation therapy is given for breast cancer. A beam of radiation is focused onto the affected area by an external machine. The extent of the treatment is determined by a health-care team and is based on the surgical procedure performed and whether lymph nodes were affected or not.

    The local area will usually be marked after the radiation team has determined the exact location for the treatments. Usually, the treatment is given five days a week for five to six weeks.

    Brachytherapy

    This form of delivering radiation uses radioactive seeds or pellets. Instead of a beam from the outside delivering the radiation, these seeds are implanted into the breast next to the cancer.

    Chemotherapy

    Chemotherapy is treatment of cancers with medications that travel through the bloodstream to the cancer cells. These medications are given either by intravenous injection or by mouth.

    Chemotherapy can have different indications and may be performed in different settings as follows:

    Adjuvant chemotherapy: If surgery has removed all the visible cancer, there is still the possibility that cancer cells have broken off or are left behind. If chemotherapy is given to assure that these small amounts of cells are killed as well, it is called adjunct chemotherapy.

    Neoadjuvant chemotherapy: If chemotherapy is given before surgery, it is referred to as neoadjuvant chemotherapy. Although there seems to be no advantage to long-term survival whether the therapy is given before or after surgery, there are advantages to see if the cancer responds to the therapy and by shrinking the cancer before surgical removal.

    Chemotherapy for advanced cancer: If the cancer has metastasized to distant sites in the body, chemotherapy can be used for treatment. In this case, the health-care team will need to determine the most appropriate length of treatment.

    There are many different chemotherapeutic agents that are either given alone or in combination. Usually, these drugs are given in cycles with certain treatment intervals followed by a rest period. The cycle length and rest intervals differ from drug to drug.

    Hormone therapy

    This therapy is often used to help reduce the risk of cancer reoccurrence after surgery, but it can also be used as adjunct treatment.

    Estrogen (a hormone produced by the ovaries) promotes the growth of a few breast cancers, specifically those containing receptors for estrogen (ER positive) or progesterone (PR positive). The following drugs are used in hormone therapy:

    • Tamoxifen (Nolvadex): This drug prevents estrogen from binding to estrogen receptors on breast cells.
    • Toremifene (Fareston) works similar to Tamoxifen and is only indicated in metastatic breast cancer.
    • Fulvestrant (Faslodex): This drug eliminates the estrogen receptor and can be used even if tamoxifen is no longer useful.
    • Aromatase inhibitors: They stop estrogen production in postmenopausal women. Examples are letrozole (Femara), anastrozole (Arimidex), and exemestane (Aromasin).

    Learn more about: Nolvadex | Fareston | Faslodex | Femara | Arimidex | Aromasin

    Targeted therapy

    As we are learning more about gene changes and their involvement in causing cancer, drugs are being developed that specifically target the cancer cells. They tend to have fewer side effects then chemotherapy (as they target only the cancer cells) but usually are still used in adjunct with chemotherapy.

    Targeting HER2/Neu protein

    Monoclonal antibody: Trastuzumab is an engineered protein that attaches to the HER2/Neu protein on breast cancer cells. It helps slow the growth of the cancer cell and may also stimulate the immune system to attack the cancer cell more effectively.

    It is given IV either once a week or every three weeks. The following are other examples of drugs targeting HER2 cells.

    • Pertuzumab (Perjeta)
    • Lapatinib (Tykerb)
    • Ado-trastuzumab (Kadcyla): A combination drug of a HER2 targeting drug that releases a cell-killing drug once attached to the cancer cells.

    Learn more about: Perjeta | Tykerb | Kadcyla

    Each one of these drugs has very specific indication and uses depending on other therapies already in progress.

    Alternative treatments

    Whenever a disease has the potential for much harm and death, physicians search for alternative treatments. As a patient or the loved one of a patient, there may be an inclination to try everything and leave no option unexplored. The danger in this approach is usually found in the fact that the patient might not avail themselves of existing, proven therapies. One should discuss any interest in alternative treatments with a health-care team and together explore the different options.

    Is it possible to prevent breast cancer?

    There is no guaranteed way to prevent breast cancer. Reviewing the risk factors and modifying the ones that can be altered (increase exercise, keep a good body weight, etc.) can help in decreasing the risk.

    Following the American Cancer Society's guidelines for early detection can help early detection and treatment.

    There are some subgroups of women that should consider additional preventive measures.

    Women with a strong family history of breast cancer should be evaluated by genetic testing. This should be discussed with a health-care provider and be preceded by a meeting with a genetic counselor who can explain what the testing can and cannot tell and then help interpret the results after testing.

    Chemoprevention is the use of medications to reduce the risk of cancer. The two currently approved drugs for chemoprevention of breast cancer are tamoxifen (a medication that blocks estrogen effects on the breast tissue) and raloxifene (Evista), which also blocks the effect of estrogen on breast tissues. Their side effects and whether these medications are right for an individual need to be discussed with a health-care provider.

    Learn more about: Evista

    Aromatase inhibitors are medications that block the production of small amounts of estrogen usually produced in postmenopausal women. They are being used to prevent reoccurrence of breast cancer but are not approved at this time for breast cancer chemoprevention.

    For a small group of patients who have a very high risk of breast cancer, surgery to remove the breasts may be an option. Although this reduces the risk significantly, a small chance of developing cancer remains.

    What research is being done on breast cancer? Is it worthwhile to participate in a clinical trial?

    Without research and clinical trials, there would be no progress in our treatment of cancers.

    Research can take many forms, including research directly on cancer cells or using animals.

    Research that a patient can be involved in is referred to as a clinical trial. In clinical trials, different treatment regimens are compared for side effects and outcomes, including long-term survival. Clinical trials are designed to find out whether new approaches are safe and effective.

    Whether one should participate in a clinical trial is a personal decision and should be based upon a full understanding of the advantages and disadvantages of the trial. One should discuss the trial with a health-care team and ask how this trial might be different from the treatment one would usually receive.

    Someone should never be forced to participate in a clinical trial or be involved in a trial without full understanding of the trial and a written and signed consent.

    I may have breast cancer, what questions should I ask my doctor?

    If you have received a positive or possible diagnosis of breast cancer, there are a number of questions that you can ask your doctor. The answers you receive to these questions should give you a better understanding of your specific diagnosis and the corresponding treatment. It is usually helpful to write your questions down before you meet with your health-care provider. This gives you the opportunity to ask all your questions in an organized fashion.

    Each question is followed by a brief explanation as to why that particular question is important. We will not attempt to answer these questions in detail here because each individual case is just that, individual. This outline is designed to provide a framework to help you and your family make certain that most of the important questions in breast cancer diagnosis and treatment have been addressed. As cancer treatments are constantly evolving, specific recommendations and treatments might change and you should always confer with your treatment team regarding any questions. You obviously should add your own questions and concerns to these when you have a discussion with your doctor.

    Is the doctor sure I have breast cancer?

    Certain types of cancer are relatively easy to identify by standard microscopic evaluation of the tissue. This is generally true for the most common types of breast cancer. This obviously implies that you have had a biopsy (removal of some tissue at the possible cancer site) that was then reviewed by a pathologist.

    However, as the search for earlier and rarer forms of breast cancer progresses, it can be difficult to be certain that a particular group of cells is malignant (cancerous). At the same time, benign conditions may have cells which are somewhat distorted in appearance or pattern of growth (known as atypical cells or atypical hyperplasia). For this reason, it is important that the pathologist reading the slides of your breast biopsy be experienced in breast pathology. Most good pathology groups have multiple pathologists review questionable or troublesome slides. In more difficult cases, the slides will often be sent to recognized specialists with considerable expertise in breast pathology.

    What type of breast cancer do I have?

    Breast cancer is not a single disease. There are many types of breast cancer, and they may have vastly different implications. Breast cancers range from localized cancers such as ductal carcinoma in situ (DCIS) to invasive cancers that can rapidly spread (metastasize). In the middle of the spectrum are breast cancers, such as colloid carcinomas and papillary carcinomas, which have a much more favorable outlook (prognosis) than the other more typically invasive breast cancers. Sometimes, noninvasive DCIS is found around invasive breast cancers.

    The treatment team should be able to explain what type of cancer you have, how they determined this, and the treatment they recommend.

    What difference does a precise diagnosis make?

    The importance of an accurate diagnosis cannot be overstated. It is the precise diagnosis that determines the recommended treatment. Treatment must be specifically tailored to the specific type of breast cancer as well as to the individual patient.

    A doctor should be able to give someone a clear description of the type of breast cancer along with the treatment options that are appropriate to one's case.

    What has been done to exclude cancer in other areas of the same breast or in my other breast?

    Unfortunately, there are some patients who may have more than one area of malignancy in the same breast or even an additional malignancy in the other breast. If this does occur, it can greatly change the recommendations for treatment.

    Therefore, it is critically important that your doctors carefully investigate beyond the immediate site of the tumor to make certain there are no other areas with possible malignancy.

    Sometimes discovering these "secondary" areas requires careful review of your mammograms. It may also require the addition of special views from different angles and specialized examination of your breasts by ultrasound, MRI, or other imaging techniques. Sometimes imaging techniques will be used to evaluate the rest of your body, as well.

    What are the different types of breast cancer?

    There are many types of breast cancer. Some are more common than others, and there are also combinations of cancers. Some of the most common types of cancer are as follows:

    Ductal carcinoma in situ: The most common type of noninvasive breast cancer is ductal carcinoma in situ (DCIS). This type of cancer has not spread and therefore usually has a very high cure rate.

    Invasive ductal carcinoma: This cancer starts in a duct of the breast and grows into the surrounding tissue. It is the most common form of breast cancer. About 80% of invasive breast cancers are invasive ductal carcinoma.

    Invasive lobular carcinoma: This breast cancer starts in the glands of the breast that produce milk. Approximately 10% of invasive breast cancers are invasive lobular carcinoma.

    The remainder of breast cancers are much less common and include the following:

    Mucinous carcinoma are formed from mucus-producing cancer cells. Mixed tumors contain a variety of cell types. Medullary carcinoma is an infiltrating breast cancer that presents with well-defined boundaries between the cancerous and noncancerous tissue.

    Inflammatory breast cancer: This cancer makes the skin of the breast appear red and feel warm (giving it the appearance of an infection). These changes are due to the blockage of lymph vessels by cancer cells.

    Triple-negative breast cancers: This is a subtype of invasive cancer with cells that lack estrogen and progesterone receptors and have no excess of a specific protein (HER2) on their surface. It tends to appear more often in younger women and African-American women.

    Paget's disease of the nipple: This cancer starts in the ducts of the breast and spreads to the nipple and the area surrounding the nipple. It usually presents with crusting and redness around the nipple.

    Adenoid cystic carcinoma: These cancers have both glandular and cystic features. They tend not to spread aggressively and have a good prognosis.

    The following are other uncommon types of breast cancer:

    • Papillary carcinoma
    • Phyllodes tumor
    • Angiosarcoma
    • Tubular carcinoma

    What are the statistics on male breast cancer?

    Breast cancer is rare in men (approximately 2,000 new cases diagnosed per year in the U.S.) but typically has a significantly worse outcome. This is partially related to the often late diagnosis of male breast cancer, when the cancer has already spread.

    Symptoms are similar to the symptoms in women, with the most common symptom being a lump or change in skin of the breast tissue or nipple discharge. Although it can occur at any age, male breast cancer usually occurs in men over 60.

    What causes breast cancer?

    There are many risk factors that increase the chance of developing breast cancer. Although we know some of these risk factors, we don't know how these factors cause the development of a cancer cell.

    What are breast cancer risk factors?

    Some of the breast cancer risk factors can be modified (such as alcohol use) while others cannot be influenced (such as age). It is important to discuss these risks with a health-care provider anytime new therapies are started (for example, postmenopausal hormone therapy).

    The following are risk factors for breast cancer:

    • Age: The chances of breast cancer increase as one gets older.
    • Family history: The risk of breast cancer is higher among women who have relatives with the disease. Having a close relative with the disease (sister, mother, daughter) doubles a woman's risk.
    • Personal history: Having been diagnosed with breast cancer in one breast increases the risk of cancer in the other breast or the chance of an additional cancer in the original breast.
    • Women diagnosed with certain benign breast conditions have an increased risk of breast cancer. These include atypical hyperplasia, a condition in which there is abnormal proliferation of breast cells but no cancer has developed.
    • Menstruation: Women who started their menstrual cycle at a younger age (before 12) or went through menopause later (after 55) have a slightly increased risk.
    • Breast tissue: Women with dense breast tissue (as documented by mammogram) have a higher risk of breast cancer.
    • Race: White women have a higher risk of developing breast cancer, but African-American women tend to have more aggressive tumors when they do develop breast cancer.
    • Exposure to previous chest radiation or use of diethylstilbestrol increases the risk of breast cancer.
    • Having no children or the first child after age 30 increases the risk of breast cancer.
    • Breastfeeding for one and a half to two years might slightly lower the risk of breast cancer.
    • Being overweight or obese increases the risk of breast cancer.
    • Use of oral contraceptives in the last 10 years increases the risk of breast cancer.
    • Using combined hormone therapy after menopause increases the risk of breast cancer.
    • Alcohol use increases the risk of breast cancer, and this seems to be proportional to the amount of alcohol used.
    • Exercise seems to lower the risk of breast cancer.
    • Genetic risk factors: The most common causes are mutations in the BRCA1 and BRCA2 genes. Inheriting a mutated gene from a parent means that one has a significantly higher risk of developing breast cancer.

    What are breast cancer symptoms and signs?

    The most common sign of breast cancer is a new lump or mass in the breast. In addition, the following are possible signs of breast cancer:

    • Thickening or lump in the breast that feels different from the surrounding area
    • Inverting of the nipple (as a change from previous appearance)
    • Nipple discharge or redness (especially any bloody discharge)
    • Breast or nipple pain
    • Swelling of part of the breast or dimpling
    • Changes in the skin of the breast

    One should discuss these or any other concerning findings with a health-care professional.

    How do physicians diagnose breast cancer?

    Although breast cancer can be diagnosed by the above signs and symptoms, the use of screening mammography has made it possible to detect many of the cancers early before they cause any symptoms.

    The American Cancer Society has the following recommendations for breast cancer screenings:

    Women age 40 and older should have a screening mammogram every year and should continue to do so as long as they are in good health.

    Mammograms are a very good screening tool for breast cancer. As in any test, mammograms have limitations and will miss some cancers. An individual's family history and mammogram and breast exam results should be discussed with a health-care provider.

    Women in their 20s and 30s should have a clinical breast exam (CBE) as part of regular health exams by a health-care professional about every three years for women in their 20s and 30s and every year for women 40 years of age and over.

    Clinical breast exams are an important tool to detect changes in the breast and also trigger a discussion with a health-care provider about early cancer detection and risk factors.

    Breast self-exam (BSE) is an option for women starting in their 20s. Women should report any breast changes to their health-care professional.

    If a woman wishes to do BSE, the technique should be reviewed with her health-care provider. The goal is to feel comfortable with the way the woman's breast feels and looks and therefore detect changes.

    Women at high risk (greater than 20% lifetime risk) should get an MRI and a mammogram every year. Women at moderate risk (15%-20%) should talk to their doctor about the benefits and limitations of adding MRI screening to their yearly mammogram.

    How is breast cancer staging determined?

    Staging is the process of determining the extent of the cancer and its spread in the body. Together with the type of cancer, staging is used to determine the appropriate therapy and to predict chances for survival.

    To determine if the cancer has spread, several different imaging techniques can be used.

    Chest X-ray: It looks for spread of the cancer to the lung.

    Mammograms: More detailed and additional mammograms provide more images of the breast and may locate other abnormalities.

    Computerized tomography (CT scan): These specialized X-rays are used to look at different parts of your body to determine if the breast cancer has spread. It could include a CT of the brain, lungs, or any other area of concern.

    Bone scan: A bone scan determines if the cancer has spread (metastasized) to the bones. Low level radioactive material is injected into the bloodstream, and over a few hours, images are taken to determine if there is uptake in certain bone areas, indicating metastasis.

    Positron emission tomography (PET scan): A radioactive material is injected that is absorbed preferentially by rapidly growing cells (such as cancer cells). The PET scanner then locates these areas in your body.

    Staging system

    This system is used by a health-care team to summarize in a standard way the extent and spread of the cancer. This staging can then be used to determine the treatment most appropriate for the type of cancer.

    The most widely used system in the U.S. is the American Joint Committee on Cancer TNM system.

    Besides the information gained from the imaging tests, this system also uses the results from surgical procedures. After surgery, a pathologist looks at the cells from the breast cancer as well as from the lymph nodes. This information gained is incorporated into the staging as it tends to be more accurate than the physical exam and X-ray findings alone.

    TNM staging. This system uses letters and numbers to describe certain tumor characteristics in a uniform manner. This allows health-care providers to stage the cancer (which helps determine the most appropriate therapy) and aids communication among health-care providers.

    T: describes the size of the tumor. It is followed by a number from 0 to 4. Higher numbers indicate a larger tumor or greater spread:

    TX: Primary tumor cannot be assessed
    T0: No evidence of primary tumor
    Tis: Carcinoma in situ
    T1: Tumor is 2 cm or less across
    T2: Tumor is 2 cm-5 cm
    T3: Tumor is more than 5 cm
    T4: Tumor of any size growing into the chest wall or skin.

    N: describes the spread to lymph node near the breast. It is followed by a number from 0 to 3.

    NX: Nearby lymph nodes cannot be assessed (for example if they have previously been removed).
    N0: There has been no spread to nearby lymph nodes. In addition to the numbers, this part of the staging is modified by the designation "i+" if the cancer cells are only seen by immunohistochemistry (a special stain) and "mol+" if the cancer could only be found using PCR (special detection technique to detect cancer at the molecular level).
    N1: Cancer has spread to one to three axillary lymph nodes (underarm lymph nodes) or tiny amounts of cancer are found in internal mammary lymph nodes (lymph nodes near breastbone).
    N2: Cancer has spread to four to nine axillary lymph nodes or the cancer has enlarged the internal mammary lymph nodes.
    N3: Any of the conditions below

    • Cancer has spread to 10 or more axillary lymph nodes with at least one cancer spread larger than 2 mm.
    • Cancer has spread to lymph nodes under the clavicle with at least area of cancer spread greater than 2 mm.

    M: This letter is followed by a 0 or 1, indicating whether the cancer has spread to other organs.

    MX: Metastasis cannot be assessed.
    M0: No distant spread is found on imaging procedures or by physical exam.
    M1: Spread to other organs is present.

    Once the T, N, and M categories have been determined, they are combined into staging groups. There are five major staging groups, stage 0 to stage IV, which are subdivided into A and B, or A and B and C, depending on the underlying cancer and the T, N, and M scale.

    Cancers with similar stages often require similar treatments.

    What is the prognosis of breast cancer?

    Survival rates are a way for health-care professionals to discuss the prognosis and outlook of a cancer diagnosis with their patients. Patients have to determine if they want to know this number or not and should let their health-care providers know.

    The number most frequently discussed is five-year survival. It is the percentage of patients who live at least five years after they are diagnosed with cancer. Many of these patients live much longer, and some patients die earlier from causes other than breast cancer. With a constant change in therapies, these numbers also change. The current five-year survival statistic is based on patients who were diagnosed at least five years ago and may have received different therapies than are available today.

    All of this needs to be taken into consideration when interpreting these numbers for oneself.

    Below are the statistics from the National Cancer Institute's SEER database.

    StageFive-year survival rate0100%I100%II93%III72%IV22%

    These statistics are for all patients diagnosed and reported. Several recent studies have looked at different racial survival statistics and have found a higher mortality (death rate) in African-American women compared to white women in the same geographic area.

    What is the treatment for breast cancer?

    Patients with breast cancer have many treatment options. Most treatments are adjusted specifically to the type of cancer and the staging group. Treatment options should be discussed with a health-care team. The following are the basic treatment modalities used in the treatment of breast cancer.

    Surgery

    Most women with breast cancer will require surgery. Broadly, the surgical therapies for breast cancer can be divided into breast-conserving surgery and mastectomy.

    Breast-conserving surgery

    This surgery will only remove part of the breast (sometimes referred to as partial mastectomy). The extent of the surgery is determined by the size and location of the tumor.

    In a lumpectomy, only the breast lump and some surrounding tissue is removed. The surrounding tissue (margins) are inspected for cancer cells. If no cancer cells are found, this is called "negative" or "clear margins." Frequently, radiation therapy is given after lumpectomies.

    Mastectomy

    During a mastectomy (sometimes also referred to as a simple mastectomy), all the breast tissue is removed. If immediate reconstruction is considered, a skin-sparing mastectomy is sometimes performed. In this surgery, all the breast tissue is removed as well but the overlying skin is preserved.

    Radical mastectomy

    During this surgery, the surgeon removes the axillary lymph nodes as well as the chest wall muscle in addition to the breast. This procedure is done much less frequently than in the past, as in most cases, a modified radical mastectomy is as effective.

    Modified radical mastectomy

    This surgery removes the axillary lymph nodes in addition to the breast tissue. Depending on the stage of the cancer, a health-care team might give someone a choice between a lumpectomy and a mastectomy. Lumpectomy allows sparing of the breast but usually requires radiation therapy afterward. If lumpectomy is indicated, long-term follow-up shows no advantage of a mastectomy over the lumpectomy.

    Preventive surgery

    For a small group of patients who have a very high risk of breast cancer, surgery to remove the breasts may be an option. Although this reduces the risk significantly, a small chance of developing cancer remains.

    Double mastectomy is a surgical option to prevent breast cancer. This prophylactic (preventive) surgery can decrease the risk of breast cancer by about 90% for women at moderate to high risk for breast cancer.

    Such an approach should be carefully discussed with a health-care team.

    The discussion about whether to undergo any preventive surgery should include

    • genetic testing for BRCA1 or BRCA2 gene mutations,
    • full review of risk factors,
    • family history of cancer and specifically breast cancer,
    • other preventive options such as medications.
    Radiation therapy

    Radiation therapy destroys cancer cells with high energy rays. There are two ways to administer radiation therapy.

    External beam radiation

    This is the usual way radiation therapy is given for breast cancer. A beam of radiation is focused onto the affected area by an external machine. The extent of the treatment is determined by a health-care team and is based on the surgical procedure performed and whether lymph nodes were affected or not.

    The local area will usually be marked after the radiation team has determined the exact location for the treatments. Usually, the treatment is given five days a week for five to six weeks.

    Brachytherapy

    This form of delivering radiation uses radioactive seeds or pellets. Instead of a beam from the outside delivering the radiation, these seeds are implanted into the breast next to the cancer.

    Chemotherapy

    Chemotherapy is treatment of cancers with medications that travel through the bloodstream to the cancer cells. These medications are given either by intravenous injection or by mouth.

    Chemotherapy can have different indications and may be performed in different settings as follows:

    Adjuvant chemotherapy: If surgery has removed all the visible cancer, there is still the possibility that cancer cells have broken off or are left behind. If chemotherapy is given to assure that these small amounts of cells are killed as well, it is called adjunct chemotherapy.

    Neoadjuvant chemotherapy: If chemotherapy is given before surgery, it is referred to as neoadjuvant chemotherapy. Although there seems to be no advantage to long-term survival whether the therapy is given before or after surgery, there are advantages to see if the cancer responds to the therapy and by shrinking the cancer before surgical removal.

    Chemotherapy for advanced cancer: If the cancer has metastasized to distant sites in the body, chemotherapy can be used for treatment. In this case, the health-care team will need to determine the most appropriate length of treatment.

    There are many different chemotherapeutic agents that are either given alone or in combination. Usually, these drugs are given in cycles with certain treatment intervals followed by a rest period. The cycle length and rest intervals differ from drug to drug.

    Hormone therapy

    This therapy is often used to help reduce the risk of cancer reoccurrence after surgery, but it can also be used as adjunct treatment.

    Estrogen (a hormone produced by the ovaries) promotes the growth of a few breast cancers, specifically those containing receptors for estrogen (ER positive) or progesterone (PR positive). The following drugs are used in hormone therapy:

    • Tamoxifen (Nolvadex): This drug prevents estrogen from binding to estrogen receptors on breast cells.
    • Toremifene (Fareston) works similar to Tamoxifen and is only indicated in metastatic breast cancer.
    • Fulvestrant (Faslodex): This drug eliminates the estrogen receptor and can be used even if tamoxifen is no longer useful.
    • Aromatase inhibitors: They stop estrogen production in postmenopausal women. Examples are letrozole (Femara), anastrozole (Arimidex), and exemestane (Aromasin).

    Learn more about: Nolvadex | Fareston | Faslodex | Femara | Arimidex | Aromasin

    Targeted therapy

    As we are learning more about gene changes and their involvement in causing cancer, drugs are being developed that specifically target the cancer cells. They tend to have fewer side effects then chemotherapy (as they target only the cancer cells) but usually are still used in adjunct with chemotherapy.

    Targeting HER2/Neu protein

    Monoclonal antibody: Trastuzumab is an engineered protein that attaches to the HER2/Neu protein on breast cancer cells. It helps slow the growth of the cancer cell and may also stimulate the immune system to attack the cancer cell more effectively.

    It is given IV either once a week or every three weeks. The following are other examples of drugs targeting HER2 cells.

    • Pertuzumab (Perjeta)
    • Lapatinib (Tykerb)
    • Ado-trastuzumab (Kadcyla): A combination drug of a HER2 targeting drug that releases a cell-killing drug once attached to the cancer cells.

    Learn more about: Perjeta | Tykerb | Kadcyla

    Each one of these drugs has very specific indication and uses depending on other therapies already in progress.

    Alternative treatments

    Whenever a disease has the potential for much harm and death, physicians search for alternative treatments. As a patient or the loved one of a patient, there may be an inclination to try everything and leave no option unexplored. The danger in this approach is usually found in the fact that the patient might not avail themselves of existing, proven therapies. One should discuss any interest in alternative treatments with a health-care team and together explore the different options.

    Is it possible to prevent breast cancer?

    There is no guaranteed way to prevent breast cancer. Reviewing the risk factors and modifying the ones that can be altered (increase exercise, keep a good body weight, etc.) can help in decreasing the risk.

    Following the American Cancer Society's guidelines for early detection can help early detection and treatment.

    There are some subgroups of women that should consider additional preventive measures.

    Women with a strong family history of breast cancer should be evaluated by genetic testing. This should be discussed with a health-care provider and be preceded by a meeting with a genetic counselor who can explain what the testing can and cannot tell and then help interpret the results after testing.

    Chemoprevention is the use of medications to reduce the risk of cancer. The two currently approved drugs for chemoprevention of breast cancer are tamoxifen (a medication that blocks estrogen effects on the breast tissue) and raloxifene (Evista), which also blocks the effect of estrogen on breast tissues. Their side effects and whether these medications are right for an individual need to be discussed with a health-care provider.

    Learn more about: Evista

    Aromatase inhibitors are medications that block the production of small amounts of estrogen usually produced in postmenopausal women. They are being used to prevent reoccurrence of breast cancer but are not approved at this time for breast cancer chemoprevention.

    For a small group of patients who have a very high risk of breast cancer, surgery to remove the breasts may be an option. Although this reduces the risk significantly, a small chance of developing cancer remains.

    What research is being done on breast cancer? Is it worthwhile to participate in a clinical trial?

    Without research and clinical trials, there would be no progress in our treatment of cancers.

    Research can take many forms, including research directly on cancer cells or using animals.

    Research that a patient can be involved in is referred to as a clinical trial. In clinical trials, different treatment regimens are compared for side effects and outcomes, including long-term survival. Clinical trials are designed to find out whether new approaches are safe and effective.

    Whether one should participate in a clinical trial is a personal decision and should be based upon a full understanding of the advantages and disadvantages of the trial. One should discuss the trial with a health-care team and ask how this trial might be different from the treatment one would usually receive.

    Someone should never be forced to participate in a clinical trial or be involved in a trial without full understanding of the trial and a written and signed consent.

    What type of breast cancer do I have?

    Breast cancer is not a single disease. There are many types of breast cancer, and they may have vastly different implications. Breast cancers range from localized cancers such as ductal carcinoma in situ (DCIS) to invasive cancers that can rapidly spread (metastasize). In the middle of the spectrum are breast cancers, such as colloid carcinomas and papillary carcinomas, which have a much more favorable outlook (prognosis) than the other more typically invasive breast cancers. Sometimes, noninvasive DCIS is found around invasive breast cancers.

    The treatment team should be able to explain what type of cancer you have, how they determined this, and the treatment they recommend.

    What difference does a precise diagnosis make?

    The importance of an accurate diagnosis cannot be overstated. It is the precise diagnosis that determines the recommended treatment. Treatment must be specifically tailored to the specific type of breast cancer as well as to the individual patient.

    A doctor should be able to give someone a clear description of the type of breast cancer along with the treatment options that are appropriate to one's case.

    What has been done to exclude cancer in other areas of the same breast or in my other breast?

    Unfortunately, there are some patients who may have more than one area of malignancy in the same breast or even an additional malignancy in the other breast. If this does occur, it can greatly change the recommendations for treatment.

    Therefore, it is critically important that your doctors carefully investigate beyond the immediate site of the tumor to make certain there are no other areas with possible malignancy.

    Sometimes discovering these "secondary" areas requires careful review of your mammograms. It may also require the addition of special views from different angles and specialized examination of your breasts by ultrasound, MRI, or other imaging techniques. Sometimes imaging techniques will be used to evaluate the rest of your body, as well.

    Source: http://www.rxlist.com

    Survival rates are a way for health-care professionals to discuss the prognosis and outlook of a cancer diagnosis with their patients. Patients have to determine if they want to know this number or not and should let their health-care providers know.

    The number most frequently discussed is five-year survival. It is the percentage of patients who live at least five years after they are diagnosed with cancer. Many of these patients live much longer, and some patients die earlier from causes other than breast cancer. With a constant change in therapies, these numbers also change. The current five-year survival statistic is based on patients who were diagnosed at least five years ago and may have received different therapies than are available today.

    All of this needs to be taken into consideration when interpreting these numbers for oneself.

    Below are the statistics from the National Cancer Institute's SEER database.

    StageFive-year survival rate0100%I100%II93%III72%IV22%

    These statistics are for all patients diagnosed and reported. Several recent studies have looked at different racial survival statistics and have found a higher mortality (death rate) in African-American women compared to white women in the same geographic area.

    Source: http://www.rxlist.com

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