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Breast Cancer

Overview

Breast cancer is second only to lung cancer as the leading cause of cancer deaths among women in the United States. The American Cancer Society estimates that more than 182,400 women will be diagnosed with breast cancer each year, while 40,480 women will lose their lives to this disease. Breast cancer will affect one of every eight American women in their lifetime. Men are also susceptible to breast cancer, although the disease is much less common among males. Nearly 2,000 men will be diagnosed with breast cancer annually, and 450 men will die.

Types

Ductal carcinoma is the most common form of breast cancer. Tumors form in the cells of the milk ducts, which convey milk to the nipples. Ductal carcinoma can either be invasive, with the potential to spread, or non-invasive.

Lobular carcinoma occurs in the lobules, which are the milk-producing glands. Lobular carcinoma can be invasive, with a tendency to spread, or non-invasive.

Inflammatory breast cancer (IBC) is a rare, aggressive form of breast cancer that affects the dermal lymphatic system. Rather than forming a lump, IBC tumors grow in flat sheets that cannot be felt in a breast exam.

Recurrent breast cancer means that the cancer has returned after being undetected for a time. Recurrent cancer can occur in the remaining breast tissue, and also at other sites such as the lungs, liver, bones or brain. Even though these tumors are in a new location, they are still called breast cancer.

Symptoms

Common symptoms of breast cancer include:

  • A change in how the breast or nipple feels
    • A lump or thickening in or near the breast or in the underarm area
    • Nipple tenderness
  • A change in how the breast or nipple looks
  • A change in the size or shape of the breast
  • A nipple turned inward into the breast
  • The skin of the breast, areola or nipple may be scaly, red or swollen. It may have ridges or pitting so that it looks like the skin of an orange.
  • Nipple discharge (fluid)

Early breast cancer usually does not cause pain. Still a woman should see her physician about breast pain or any other symptom that does not go away. Most often, these symptoms are not due to cancer. Other health problems may also cause them. Any woman with these symptoms should tell her physician so that problems can be diagnosed and treated as early as possible.

Diagnosis

If you have a symptom or screening test result that suggest cancer, your doctor must find out whether it is due to cancer or to some other cause. Your doctor may ask about your personal and family medical history. You may have a physical exam. Your doctor also may order a mammogram or other imaging procedure. These tests make pictures of tissues inside the breast. After the tests, your doctor may decide no other exams are needed. Your doctor may suggest that you have a follow-up exam later on. Or you may need to have a biopsy to look for cancer cells.

Clinical Breast Exam

Your health care provider feels each breast for lumps and looks for other problems. If you have a lump, your health care provider will feel its size, shape and texture. Your health care provider will also check to see if it moves easily. Benign lumps often feel different than cancerous ones. Lumps that are soft, smooth, round and moveable are likely to be benign. A hard, oddly shaped lump that feels firmly attached within the breast is more likely to be cancer.

Diagnostic Mammogram

Diagnostic mammograms are x-ray pictures of the breast. They take clearer, more detailed images of areas that look abnormal on a screening mammogram. Doctors use them to learn more about unusual breast changes, such as a lump, pain, thickening, nipple discharge or change in breast size or shape. Diagnostic mammograms may focus on a specific area of the breast. They may involve special techniques and more views than screening mammograms.

Ultrasound

An ultrasound device sends out sound waves that people can't hear. The waves bounce off tissues. A computer uses the echoes to create a picture. Your doctor can view these pictures on a monitor. The pictures may show whether a lump is solid or filled with fluid. A cyst is a fluid-filled sac. Cysts are not cancer. But a solid mass may be cancer. After the test, your doctor can store the pictures on video or print them out. This exam may be used along with a mammogram.

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) uses a powerful magnet linked to a computer. MRI makes detailed pictures of breast tissue. Your doctor can view these pictures on a monitor or print them on film. MRI may be used along with a mammogram.

Biopsy

Your doctor may refer you to a surgeon or breast disease specialist for a biopsy. Fluid or tissue is removed from your breast to help find out if there is cancer.

Some suspicious areas can be seen on a mammogram but can't be felt during a clinical breast exam. Doctors can use imaging procedures to help see the area and remove tissue. Such procedures include ultrasound-guided, needle-localized or stereotactic biopsy.

Doctors can remove tissue from the breast in different ways:

  • Fine-needle aspiration: your doctor uses a thin needle to remove fluid from a breast lump. If the fluid appears to contain cells, a pathologist at a lab checks them for cancer with a microscope. If the fluid is clear, it may not need to be checked by a lab.
  • Core biopsy: your doctor uses a thick needle to remove breast tissue. A pathologist checks for cancer cells. This procedure is also called a needle biopsy.
  • Surgical biopsy: your surgeon removes a sample of tissue. A pathologist checks the tissue for cancer cells.
    • An incisional biopsy takes a sample of a lump or abnormal area.
    • An excisional biopsy takes the entire lump or area.

If cancer cells are found, the pathologist can tell what kind of cancer it is. The most common type of breast cancer is ductal carcinoma. Abnormal cells are found in the lining of the ducts. Lobular carcinoma is another type. Abnormal cells are found in the lobules.

Additional Tests

If you are diagnosed with cancer, your doctor may order special lab tests on the breast tissue that was removed. These tests help your doctor learn more about the cancer and plan treatment:

  • Hormone receptor test: this test show whether the tissue has certain hormone receptors. Tissue with these receptors needs hormones (estrogen or progesterone) to grow.
  • HER2 test: this test shows whether the tissue has a protein called human epidermal growth factor receptor-2 (HER2) or the HER2/neu gene. Having too much protein or too many copies of the gene in the tissue may increase the chance that the breast cancer will come back after treatment.

Staging

The staging system allows doctors to help identify the extent of breast cancer involvement. By knowing the extent of disease, doctors can then determine the best treatment for each patient.

Stage 0 (carcinoma in situ): cancer has not spread from the site of origin.

There are 2 types of breast carcinoma in situ:
Ductal carcinoma in situ (DCIS) is a noninvasive condition in which abnormal cells are found in the lining of a breast duct. The abnormal cells have not spread outside the duct to other tissues in the breast. In some cases, DCIS may become invasive cancer and spread to other tissues, although it is not known at this time how to predict which lesions will become invasive.

Lobular carcinoma in situ (LCIS) is a condition in which abnormal cells are found in the lobules of the breast. This condition seldom becomes invasive cancer; however, having lobular carcinoma in situ in one breast increases the risk of developing breast cancer in either breast.

Stage I: Cancer has formed. The tumor is 2 centimeters or smaller and has not spread outside the breast.

Stage IIA: No tumor is found in the breast, but cancer is found in the axillary lymph nodes (the lymph nodes under the arm); or the tumor is 2 centimeters or smaller and has spread to the axillary lymph nodes; or the tumor is larger than 2 centimeters but not larger than 5 centimeters and has not spread to the axillary lymph nodes.

Stage IIB: The tumor is larger than 2 centimeters but not larger than 5 centimeters and has spread to the axillary lymph nodes; or the tumor is larger than 5 centimeters but has not spread to the axillary lymph nodes.

Stage IIIA: Cancer is found in axillary lymph nodes that are attached to each other or to other structures, or cancer may be found in lymph nodes near the breastbone. Cancer has spread to axillary lymph nodes that are attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone; or the tumor is larger than 2 centimeters but not larger than 5 centimeters. Cancer has spread to axillary lymph nodes that are attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone; or the tumor is larger than 5 centimeters. Cancer has spread to axillary lymph nodes that may be attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone.

Stage IIIB: The tumor may be any size and cancer: Has spread to the chest wall and/or the skin of the breast; and may have spread to axillary lymph nodes that may be attached to each other or to other structures, or cancer may have spread to lymph nodes near the breastbone.

Stage IIIC: There may be no sign of cancer in the breast or the tumor may be any size and may have spread to the chest wall and/or the skin of the breast. Also, cancer: Has spread to lymph nodes above or below the collarbone; May have spread to axillary lymph nodes or to lymph nodes near the breastbone.

Stage IIIC breast cancer is divided into operable and inoperable stages: In operable stage IIIC, the cancer is found in: 10 or more axillary lymph nodes; or Lymph nodes below the collarbone; or Axillary lymph nodes and in lymph nodes near the breastbone. In inoperable stage IIIC breast cancer, the cancer has spread to the lymph nodes above the collarbone.

Stage IV: The cancer has spread to other organs of the body, most often the bones, lungs, liver, or brain.

Treatment

Women with breast cancer have many treatment options. These include surgery, radiation therapy, chemotherapy, hormone therapy and biological therapy. Many women receive more than one type of treatment. The choice of treatment depends mainly on the stage of the disease and the hormonal status of the disease. Your doctor can describe your treatment choices and the expected results. You may want to know how treatment may change your normal activities. You may want to know how you will look during and after treatment. You and your doctor can work together to develop a treatment plan that reflects your medical needs and personal values.

Cancer treatment is either local therapy or systemic therapy:

  • Local therapy: surgery and radiation therapy are local treatments. They remove or destroy cancer in the breast. When breast cancer has spread to other parts of the body, local therapy may be used to control the disease in those specific areas.
  • Systemic therapy: chemotherapy, hormone therapy and biological therapy are systemic treatments. They enter the bloodstream and destroy or control cancer throughout the body. Some women with breast cancer have systemic therapy to shrink the tumor before surgery or radiation. Others have systemic therapy after surgery and/or radiation to prevent the cancer from coming back. Systemic treatments also are used for cancer that has spread.

Because cancer treatments often damage healthy cells and tissues, side effects are common. Side effects depend mainly on the type and extent of the treatment. Side effects may not be the same for each woman and they may change from one treatment session to the next.

Surgery

Surgery is the most common treatment for breast cancer. There are several types of surgery. Your doctor can explain each type, discuss and compare the benefits and risks, describe how each will change the way you look.

Breast-Sparing Surgery

With breast-sparing surgery a surgeon removes only your cancer and some normal tissue around it. This kind of surgery keeps your breast intact—looking a lot like it did before surgery. It is also called breast-conserving surgery, lumpectomy, segmental mastectomy, and partial mastectomy. Sometimes an excisional biopsy serves as a lumpectomy because the surgeon removes the whole lump.

The surgeon often removes the underarm lymph nodes as well. A separate incision is made. This procedure is called an axillary lymph node dissection. It shows whether cancer cells have entered the lymphatic system. After breast-sparing surgery, most women receive radiation therapy to the breast. This treatment destroys cancer cells that may remain in the breast.

Oncoplastic Surgery

Oncoplastic surgery is an innovative new surgical technique that combines advanced cancer removal with plastic surgery techniques and state-of-the-art breast imaging. The result is cancer treatment through incisions that are very small or even hidden, while creating a normal breast shape and appearance. Women with breast cancer traditionally see a surgeon to have the diseased tissue removed and then months later see a plastic surgeon for reconstruction. Today, breast surgeons with specialized training are able to successfully remove larger tumors, which allows women who may otherwise be advised to have a mastectomy choose this breast-conserving procedure instead.

The psychological and emotional benefits of oncoplastic surgery are numerous, allowing women to return more quickly and confidently to their lives. This new technique is aimed primarily at women with early-stage cancer who are candidates for breast conservation (lumpectomy), but it can also benefit patients receiving a mastectomy (total breast removal) by allowing a cosmetic approach to immediate reconstruction.

Mastectomy

In a mastectomy, the surgeon removes all of your breast and nipple. Sometimes, you will also need to have radiation therapy, chemotherapy, hormone therapy or all three types of therapy. Here are some types of mastectomy:

  • Total (simple) mastectomy. The surgeon removes your entire breast. Sometimes, the surgeon also takes out some of the lymph nodes under your arm.
  • Modified radical mastectomy. The surgeon removes all of your breast, many of the lymph nodes under your arm, the lining over your chest muscles and maybe a small chest muscle.
  • Double mastectomy. The surgeon removes both your breasts at the same time, even if your cancer is in only one breast. This surgery is rare and mostly used when the surgeon feels you have a high risk for getting cancer in the breast that does not have cancer.

Breast Reconstruction Surgery

After your breast cancer surgery, you can choose to have breast reconstruction surgery. (Most often, performed at time of surgery.) This surgery is done by a reconstructive plastic surgeon and gives you a new breast-like shape and nipple. Your surgeon can also add a tattoo that looks like the areola (the dark area around your nipple). Or you may not want any more surgery and prefer to wear a prosthesis (breast-like form) in your bra. There are two types of breast reconstruction surgery:

  • Breast implants. In this kind of surgery, a reconstructive plastic surgeon puts an implant (filled with salt water or silicone gel) under your skin or chest muscle to build a new breast-like shape. While this shape looks like a breast, you will have little feeling in it because the nerves have been cut.
    Breast implants do not last a lifetime. If you choose to have an implant, chances are you will need more surgery later on to remove or replace it. Implants can cause problems such as breast hardness, breast pain and infection. The implant may also break, move or shift. These problems can happen soon after surgery or years later.
  • Tissue flaps. In tissue flap surgery, a surgeon builds a new breast-like shape from muscle, fat and skin taken from other parts of the body. This new breast-like shape should last the rest of your life. Women who are very thin or obese, smoke or have other serious health problems often cannot have tissue flap surgery. Tissue flap is major surgery. Healing often takes longer after this surgery than if you have breast implants. You may have other problems as well. For example, you might lose strength in the part of your body where muscle was taken to build a new breast. Or you may get an infection or have trouble healing. Tissue flap surgery is best done by a reconstructive plastic surgeon who has done it many times before.

The time it takes to heal after surgery is different for each woman. Surgery causes pain and tenderness. Medicine can help control the pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more relief. Any kind of surgery also carries a risk of infection, bleeding, or other problems. You should tell your health care provider right away if you develop any problems.

You may feel off balance if you've had one or both breasts removed. You may feel more off balance if you have large breasts. This imbalance can cause discomfort in your neck and back. Also, the skin where your breast was removed may feel tight. Your arm and shoulder muscles may feel stiff and weak. These problems usually go away. The doctor, nurse, or physical therapist can suggest exercises to help you regain movement and strength in your arm and shoulder. Exercise can also reduce stiffness and pain. You may be able to begin gentle exercises within days of surgery.

Because nerves may be injured or cut during surgery, you may have numbness and tingling in your chest, underarm, shoulder, and upper arm. These feelings usually go away within a few weeks or months. But for some women, numbness does not go away. Removing the lymph nodes under the arm slows the flow of lymph fluid. The fluid may build up in your arm and hand and cause swelling. This swelling is lymphedema. Lymphedema can develop right after surgery or months to years later.

You will need to protect your arm and hand on the treated side for the rest of your life:

  • Avoid wearing tight clothing or jewelry on your affected arm
  • Carry your purse or luggage with the other arm
  • Use an electric razor to avoid cuts when shaving under your arm
  • Have shots, blood tests, and blood pressure measurements on the other arm
  • Wear gloves to protect your hands when gardening and when using strong detergents
  • Have careful manicures and avoid cutting your cuticles
  • Avoid burns or sunburns to your affected arm and hand

You should ask your doctor how to handle any cuts, insect bites, sunburn, or any other injuries to your arm or hand. Also, you should contact the doctor if your arm or hand is injured, swells, or becomes red and warm. Ask your doctor if you would benefit from Physical Therapy with a certified Lymphedema Specialist.

If lymphedema occurs, the doctor may suggest raising your arm above your heart whenever you can. The doctor may show you hand and arm exercises. Some women with lymphedema wear an elastic sleeve to improve lymph circulation. Medication, manual lymph drainage (massage), or use of a machine that gently compresses the arm may also help.

Radiation Therapy

Radiation therapy uses high-energy rays to kill cancer cells. Most women receive radiation therapy after breast-sparing surgery. Some women receive radiation therapy after a mastectomy. Treatment depends on the size of the tumor and other factors. The radiation destroys breast cancer cells that may remain in the area.

Some women have radiation therapy before surgery to destroy cancer cells and shrink the tumor. Doctors use this approach when the tumor is large or may be hard to remove. Some women have chemotherapy or hormone therapy before surgery.

Doctors use two types of radiation therapy to treat breast cancer. Some women receive both types:

  • External radiation: The radiation comes from a large machine outside the body. Most women go to a hospital or clinic for treatment. Treatments are usually 5 days a week for several weeks.
  • Internal radiation (implant radiation): Thin plastic tubes (implants) that hold a radioactive substance are put directly in the breast. The implants stay in place for several days. A woman stays in the hospital while she has implants. Doctors remove the implants before she goes home.

Side effects depend mainly on the dose and type of radiation and the part of the body that is treated.

It is common for the skin in the treated area to become red, dry, tender, and itchy. Your breast may feel heavy and tight. These problems will go away over time. Toward the end of treatment, your skin may become moist and "weepy." Exposing this area to air as much as possible can help the skin heal.

Bras and some other type of clothing may rub your skin and cause soreness. You may want to wear loose-fitting cotton clothes during this time. Gentle skin care also is important. You should check with your doctor before using any deodorants, lotions, or creams on the treated area. These effects of radiation therapy on the skin will go away. The area gradually heals once treatment is over. However, there may be a lasting change in the color of your skin.

You are likely to become very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can.

Chemotherapy

Chemotherapy uses anticancer drugs to kill cancer cells. Chemotherapy for breast cancer is usually a combination of drugs. The drugs may be given as a pill or by injection into a vein (IV). Either way, the drugs enter the bloodstream and travel throughout the body. Women with breast cancer can have chemotherapy in an outpatient part of the hospital, at the doctor's office, or at home. Some women need to stay in the hospital during treatment. Side effects depend mainly on the specific drugs and the dose. The drugs affect cancer cells and other cells that divide rapidly:

  • Blood cells: These cells fight infection, help your blood to clot, and carry oxygen to all parts of the body. When drugs affect your blood cells, you are more likely to get infections, bruise or bleed easily, and feel very weak and tired. Years after chemotherapy, the risk for developing leukemia and skin cancer is slightly increased.
  • Cells in hair roots: Chemotherapy can cause hair loss. Your hair will grow back, but it may be somewhat different in color and texture.
  • Cells that line the digestive tract: Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores.

Some drugs used for breast cancer can cause tingling or numbness in the hands or feet. This problem usually goes away after treatment is over. Other problems may not go away. In some women, the drugs used for breast cancer may weaken the heart.

Some anticancer drugs damage the ovaries. The ovaries may stop making hormones. You may have symptoms of menopause such as hot flashes and vaginal dryness. Your menstrual periods may no longer be regular or may stop. Some women become infertile (unable to become pregnant). For women over the age of 35, infertility is likely to be permanent.

On the other hand, you may remain fertile during chemotherapy and be able to become pregnant. The effects of chemotherapy on an unborn child are not known. You should talk to your doctor about birth control before treatment begins.

Hormone Therapy

Some breast tumors need hormones to grow. Hormone therapy keeps cancer cells from getting or using the natural hormones they need. These hormones are estrogen and progesterone. Lab tests can show if a breast tumor has hormone receptors. If you have this kind of tumor, you may have hormone therapy.

This treatment uses drugs or surgery:

  • Drugs: Your doctor may suggest a drug that can block the natural hormone. One drug is tamoxifen, which blocks estrogen. A drug called an aromatase inhibitor prevents the body from making the female hormone estradiol. Estradiol is a form of estrogen. If you have not gone through menopause, your doctor may give you a drug that stops the ovaries from making estrogen.
  • Surgery: If you have not gone through menopause, you may have surgery to remove your ovaries. The ovaries are the main source of the body's estrogen. A woman who has gone through menopause does not need surgery. (The ovaries produce less estrogen after menopause).

Biological Therapy

Biological therapy helps the immune system fight cancer. The immune system is the body's natural defense against disease.

Some women with breast cancer that has spread receive a biological therapy call Herceptin (trastuzumab). It is a monoclonal antibody. It is made in the laboratory and binds to cancer cells.

Herceptin is given to women whose lab tests show that a breast tumor has too much of a specific protein known as HER2. By blocking HER2, it can slow or stop the growth of the cancer cells. Herceptin is given by vein. It may be given alone or with chemotherapy. The first time a woman receives Herceptin, the most common side effects are fever and chills. Some women also have pain, weakness, nausea, vomiting, diarrhea, headaches, difficulty breathing, or rashes. Side effects usually become milder after the first treatment. Herceptin also may cause heart damage. This may lead to heart failure. Herceptin can also affect the lungs. It can cause breathing problems that require doctor assistance at once. Before you receive Herceptin, your doctor will check your heart and lungs. During treatment, your doctor will watch for signs of lung problems.

Clinical Trials

New treatments are always being tested in clinical trials and some patients with cancer may want to consider participating in one of these research studies. These studies are meant to help improve current cancer treatments or obtain information on new treatments. Talk to your doctor about the clinical trials that may be right for you.