Types of Cancer : Breast Cancer

Definition

Breast cancer is cancer that forms in the cells of the breasts. Breast cancer can occur in both men and women, but it's far more common in women.

After skin cancer, breast cancer is the most common cancer diagnosed in women in the United States. But breast cancer rates have fallen in recent years, though doctors aren't certain why. Still, for many women, breast cancer is the disease they fear most.

Public support for breast cancer awareness and research funding has helped improve the diagnosis and treatment of breast cancer. Breast cancer survival rates have increased and the number of deaths has been declining, thanks to earlier detection, new treatments and a better understanding of the disease.

Symptoms

Signs and symptoms of breast cancer may include:

• A breast lump or thickening that feels different from the surrounding tissue
• Bloody discharge from the nipple
• Change in the size or shape of a breast
• Changes to the skin over the breast, such as dimpling
• Inverted nipple
• Peeling or flaking of the nipple skin
• Redness or pitting of the skin over your breast, like the skin of an orange

When to see a doctor
If you find a lump or other change in your breast — even if a recent mammogram was normal — make an appointment with your doctor.

Causes

It's not clear what causes breast cancer. Doctors know that breast cancer occurs when some breast cells begin growing abnormally. These cells divide more rapidly than healthy cells do. The accumulating cells form a tumor that may spread (metastasize) through your breast, to your lymph nodes or to other parts of your body.

Breast cancer most often begins with cells in the milk-producing ducts. Doctors call this type of breast cancer invasive ductal carcinoma. Breast cancer may also begin in the lobules (invasive lobular carcinoma) or cells within the breast.

Researchers have identified things that can increase your risk of breast cancer. But it's not clear why some people who have no risk factors develop cancer, yet other people with risk factors never do. It's likely that breast cancer is caused by a complex combination of your genetic makeup and your environment.

Inherited breast cancer
Doctors estimate that 5 to 10 percent of breast cancers are linked to gene mutation passed through generations of a family. A number of inherited defective genes that can increase the likelihood of breast cancer have been identified. The most common are breast cancer gene 1 (BRCA1) and breast cancer gene 2 (BRCA2), both of which increase the risk of both breast and ovarian cancer.

If you have a strong family history of breast cancer or other cancers, blood tests may help identify defective BRCA or other genes that are being passed through your family. Consider asking your doctor for a referral to a genetic counselor who can review your family health history. A genetic counselor can also discuss the benefits, risks and limitations of genetic testing with you.

Risk factors

A risk factor is anything that makes it more likely you'll get a particular disease. But having one or even several risk factors doesn't necessarily mean you'll develop cancer — most women with breast cancer have no known risk factors other than simply being women.

Things that can increase your risk of breast cancer include:

• Being female. Women are much more likely than men are to develop breast cancer.
• Increasing age. Your risk of breast cancer increases as you age. Women older than 60 have a greater risk than do younger women.
• A personal history of breast cancer. If you've had breast cancer in one breast, you have an increased risk of developing cancer in the other breast.
• A family history of breast cancer. If you have a mother, sister or daughter with breast cancer, you have a greater chance of being diagnosed with breast cancer. Still, the majority of people diagnosed with breast cancer have no family history of the disease.
• Inherited genes that increase cancer risk. Certain gene mutations that increase the risk of breast cancer can be passed from parents to children. The most common gene mutations are referred to as BRCA1 and BRCA2. These genes can greatly increase your risk of breast cancer and other cancers, but they don't make cancer inevitable.
• Radiation exposure. If you received radiation treatments to your chest as a child or young adult, you're more likely to develop breast cancer later in life.
• Obesity. Being overweight or obese increases your risk of breast cancer.
• Beginning your period at a younger age. Beginning your period before age 12 increases your risk of breast cancer.
• Beginning menopause at an older age. If you began menopause after age 55, you're more likely to develop breast cancer.
• Having your first child at an older age. Women who give birth to their first child after age 35 may have an increased risk of breast cancer.
• Postmenopausal hormone therapy. Women who take hormone therapy medications that combine estrogen and progesterone to treat the signs and symptoms of menopause have an increased risk of breast cancer.
• Drinking alcohol. Drinking alcohol may increase the risk of breast cancer.

Preparing for your appointment

Consulting with your health care team
Women with breast cancer may have appointments with their primary care doctors, as well as several other doctors and other health professionals, including:

• Breast surgeons
• Doctors who specialize in diagnostic tests, such as mammograms (radiologists)
• Doctors who specialize in treating cancer (oncologists)
• Doctors who treat cancer with radiation (radiation oncologists)
• Genetic counselors
• Plastic surgeons

What you can do to prepare

• Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down key personal information, including any major stresses or recent life changes.
• Write down your family history of cancer. Note any family members who have had cancer, including how each member is related to you, the type of cancer, the age at diagnosis and whether each person survived.
• Make a list of all medications, as well as any vitamins or supplements, that you're taking.
• Keep all of your records that relate to your cancer diagnosis and treatment. Organize your records in a binder or folder that you can take to your appointments.
• Take a family member or friend along, if possible. Sometimes it can be difficult to absorb all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Write down questions to ask your doctor.

Questions to ask your doctor
Your time with your doctor is limited, so preparing a list of questions will help you make the most of your time together. List your questions from most important to least important in case time runs out. For breast cancer, some basic questions to ask your doctor include:

• What type of breast cancer do I have?
• What is the stage of my cancer?
• Can you explain my pathology report to me? Can I have a copy for my records?
• Do I need any more tests?
• What are the treatment options for my cancer?
• What are the side effects of each treatment option?
• How will each treatment option affect my daily life? Can I continue working?
• Is there one treatment you recommend over the others?
• How do you know that these treatments will benefit me?
• What would you recommend to a friend or family member in my situation?
• How quickly do I need to make a decision about cancer treatment?
• What happens if I don't want cancer treatment?
• What will cancer treatment cost?
• Does my insurance plan cover the tests and treatment you're recommending?
• Should I seek a second opinion? Will my insurance cover it?
• Are there any brochures or other printed material that I can take with me? What Web sites or books do you recommend?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.

Tests and diagnosis

Diagnosing breast cancer
Tests and procedures used to diagnose breast cancer include:

• Mammogram. A mammogram is an X-ray of the breast. Mammograms are commonly used to screen for breast cancer. If an abnormality is detected on a screening mammogram, your doctor may recommend a diagnostic mammogram to further evaluate that abnormality.
• Breast ultrasound. Ultrasound uses sound waves to produce images of structures deep within the body. Your doctor may recommend an ultrasound to help determine whether a breast abnormality is likely to be a fluid-filled cyst rather than a breast tumor.
• Breast magnetic resonance imaging (MRI). An MRI machine uses a magnet and radio waves to create pictures of the interior of your breast. Before a breast MRI, you receive an injection of dye.
• Removing a sample of breast cells for testing (biopsy). A biopsy to remove a sample of the suspicious breast cells helps determine whether cells are cancerous or not. The sample is sent to a laboratory for testing. A biopsy sample is also analyzed to determine the type of cells involved in the breast cancer, the aggressiveness (grade) of the cancer and whether the cancer cells have hormone receptors.

Other tests and procedures may be used depending on your situation.

Staging breast cancer
Once your doctor has diagnosed your breast cancer, he or she works to determine the extent (stage) of your cancer. Your cancer's stage helps determine your prognosis and your treatment options. Complete information about your cancer's stage may not be available until after you undergo breast cancer surgery.

Tests and procedures used to stage breast cancer may include:

• Blood tests, such as a complete blood count
• Mammogram of the other breast to look for signs of cancer
• Chest X-ray
• Breast MRI
• Bone scan
• Computerized tomography (CT) scan
• Positron emission tomography (PET) scan

Not all women will need all of these tests and procedures. Your doctor selects the appropriate tests.

Breast cancer stages range from 0 to IV, with 0 indicating cancer that is very small and noninvasive. Stage IV breast cancer, also called metastatic breast cancer, indicates cancer that has spread to other areas of the body.

Treatments and drugs

Your doctor determines your breast cancer treatment options based on your type of breast cancer, its stage, whether the cancer cells are sensitive to hormones, your overall health and your own preferences. Most women undergo surgery for breast cancer and also receive additional treatment, such as chemotherapy, hormone therapy or radiation.

There are many options for breast cancer treatment and you may feel overwhelmed as you make complex decisions about your treatment. Consider seeking a second opinion from a breast specialist in a breast center or clinic. Talk to other women who have faced the same decision.

Breast cancer surgery
Operations used to treat breast cancer include:

• Removing the breast cancer (lumpectomy). During lumpectomy, the surgeon removes the tumor and a small margin of surrounding healthy tissue. Lumpectomy is typically reserved for smaller tumors that are easily separated from the surrounding tissue.
• Removing the entire breast (mastectomy). Mastectomy is surgery to remove all of your breast tissue. Mastectomy can be simple, meaning the surgeon removes all of the breast tissue — the lobules, ducts, fatty tissue and skin, including the nipple and areola. Or mastectomy can be radical, meaning the underlying muscle of the chest wall is removed along with surrounding lymph nodes in the armpit.
• Removing one lymph node (sentinel node biopsy). Breast cancer that spreads to the lymph nodes may spread to other areas of the body. Your surgeon determines which lymph node near your breast tumor receives the lymph drainage from your cancer. This lymph node is removed and tested for breast cancer cells. If no cancer is found, the chance of finding cancer in any of the remaining nodes is small and no other nodes need to be removed.
• Removing several lymph nodes (axillary lymph node dissection). If cancer is found in the sentinel node, then your surgeon removes additional lymph nodes in your armpit. Knowing if cancer has spread to the lymph nodes helps determine the best course of treatment, including whether you'll need chemotherapy or radiation therapy.

Complications of breast cancer surgery depend on the procedures you choose. Surgery carries a risk of bleeding and infection. Surgery to remove your lymph nodes increases your risk of arm swelling (lymphedema).

Some women choose to have breast reconstruction after surgery. Discuss your options and preferences with your surgeon. Consider a referral to a plastic surgeon before your breast cancer surgery. Your options may include reconstruction with a synthetic breast implant or reconstruction using your own tissue. These operations can be performed at the time of your mastectomy or at a later date.

Radiation therapy
Radiation therapy uses high-powered beams of energy, such as X-rays, to kill cancer cells. Radiation therapy is typically done using a large machine that aims the energy beams at your body (external beam radiation). But radiation can also be done by placing radioactive material inside your body (brachytherapy).

External beam radiation is commonly used after lumpectomy for early-stage breast cancer. Doctors may also recommend radiation therapy after mastectomy for larger breast cancers.

Side effects of radiation therapy include fatigue and a red, sunburn-like rash where the radiation is aimed. Breast tissue may also appear swollen or more firm. Rarely, more serious problems may occur, including arm swelling (lymphedema), broken ribs and damage to the lungs or nerves.

Chemotherapy
Chemotherapy uses drugs to destroy cancer cells. If your cancer has a high chance of returning or spreading to another part of your body, your doctor may recommend chemotherapy after surgery to decrease the chance that the cancer will recur. This is known as adjuvant systemic chemotherapy.

Chemotherapy is sometimes given before surgery in women with larger breast tumors. Doctors call this neoadjuvant chemotherapy. The goal is to shrink a tumor to a size that makes it easier to remove with surgery. This may also increase the chance of a cure. Research is ongoing into neoadjuvant chemotherapy to determine who may benefit from this treatment.

Chemotherapy is also used in women whose cancer has already spread to other parts of the body. Chemotherapy may be recommended to try to control the cancer and decrease any symptoms the cancer is causing.

Chemotherapy side effects depend on the drugs you receive. Common side effects include hair loss, nausea, vomiting, fever and frequent infections.

Hormone therapy
Hormone therapy — perhaps more properly termed hormone blocking therapy — is often used to treat breast cancers that are sensitive to hormones. Doctors sometimes refer to these cancers as estrogen and progesterone receptor positive cancers.

Hormone therapy can be used after surgery or other treatments to decrease the chance of your cancer returning. If the cancer has already spread, hormone therapy may shrink and control it.

Treatments that can be used in hormone therapy include:

• Medications that block hormones from attaching to cancer cells. Tamoxifen is a type of drug called a selective estrogen receptor modulator (SERM). SERMs act by blocking any estrogen present in the body from attaching to the estrogen receptor on the cancer cells, slowing the growth of tumors and killing tumor cells. Tamoxifen can be used in both pre- and postmenopausal women.
• Medications that stop the body from making estrogen after menopause. Called aromatase inhibitors, these drugs block the action of an enzyme that converts androgens in the body into estrogen. These drugs are effective only in postmenopausal women. Aromatase inhibitors include anastrozole (Arimidex), letrozole (Femara) and exemestane (Aromasin).
• Surgery or medications to stop hormone production in the ovaries. In premenopausal women, surgery or medications can shutdown hormone production in the ovaries.

Side effects of hormone therapy vary according to which medication you receive, but typically include menopausal symptoms, such as hot flashes, vaginal dryness, decreased sex drive and mood changes. Side effects of aromatase inhibitors include joint and muscle pain, as well as an increased risk of bone thinning (osteoporosis).

Targeted drugs
Targeted drug treatments attack specific abnormalities within cancer cells. Targeted drugs approved to treat breast cancer include:

• Trastuzumab (Herceptin). Trastuzumab targets a protein called HER2 that helps some breast cancer cells grow and survive. If your breast cancer cells make too much HER2, trastuzumab may help block that protein and cause the cancer cells to die.
• Bevacizumab (Avastin). Bevacizumab is a drug designed to stop the signals cancer cells use to attract new blood vessels. Without new blood vessels to bring oxygen and nutrients to the tumor, the cancer cells die. Bevacizumab is approved for breast cancer that has spread to other areas of the body.
• Lapatinib (Tykerb). Lapatinib targets the HER2 protein and is approved for use in advanced breast cancer. Lapatinib is reserved for women who have already tried trastuzumab and their cancer has progressed.

Side effects of targeted drugs depend on the drug you receive. Targeted drugs can be very expensive and aren't always covered by health insurance.

Clinical trials
Clinical trials are used to test new and promising agents in the treatment of cancer. Clinical trials represent the cutting edge of cancer treatment, but they're often unproven treatments that may or may not be superior to currently available therapies. Talk with your doctor about clinical trials to see if one is right for you.

Examples of treatments being studied in breast cancer clinical trials include:

• New combinations of existing drugs. Researchers are studying new ways of combining existing chemotherapy, hormone therapy and targeted therapy drugs. Testing new combinations may help determine if certain breast cancers are more susceptible to specific combinations.
• Bone-building drugs to prevent breast cancer recurrence. In early 2009, a study reported adding a bone-building drug to hormone therapy treatment after surgery for premenopausal women reduced the risk of breast cancer recurrence. The drug used in the study, zoledronic acid (Reclast, Zometa), is a type of drug called a bisphosphonate that's used to treat bone loss (osteoporosis) and other bone diseases. The group of women who received zoledronic acid experienced fewer cancer recurrences than did the group that didn't receive the drug during the study, which lasted four years. Doctors are awaiting the results of other studies of zoledronic acid before widely recommending this treatment.
• Using higher doses of radiation over a shorter period of time on a smaller portion of the breast. Researchers are studying partial breast irradiation in women who've undergone lumpectomy. Partial breast irradiation involves higher doses of radiation aimed at only a portion of the breast, rather than the entire breast. Radiation used in partial breast irradiation can come from a machine outside your body or it can come from tubes or catheters placed within the breast tissue.

Alternative medicine

No alternative medicine treatments have been found to cure breast cancer. But complementary and alternative medicine therapies may help you cope with side effects of treatment when combined with your doctor's care.

Alternative medicine for fatigue
Many breast cancer survivors experience fatigue during and after treatment that can continue for years. Doctors aren't sure what causes cancer-related fatigue and it can persist despite treatment. When combined with your doctor's care, complementary and alternative medicine therapies may help relieve fatigue. Ask your doctor about:

• Gentle exercise. If you get the OK from your doctor, start with gentle exercise a few times a week and work your way up to more if you feel up to it. Consider walking, swimming, yoga or tai chi.
• Managing stress. Take control of the stress in your daily life. Try stress reduction techniques such as muscle relaxation, visualization and spending time with friends and family.
• Relaxation strategies. Balance activity with periods of relaxation. Try listening to music, writing in a journal, meditating or taking a warm bath.

Prevention

Breast cancer prevention for women with an average risk
Making changes in your daily life may help reduce your risk of breast cancer. Try to:

• Ask your doctor about breast cancer screening. Ask your doctor at what age you should begin routine clinical breast exams and mammograms. Most guidelines recommend women with an average risk begin annual mammograms to screen for breast cancer at age 40. Talk to your doctor about the benefits and risks of screening and together you can decide what breast cancer screening strategies are right for you.
• Become familiar with your breasts through breast self-exams. Ask your doctor to show you how to do a breast self-exam to check for any lumps or other unusual signs in your breasts. A breast self-exam can't prevent breast cancer, but it may help you to better understand the normal changes that your breasts undergo each month and identify any unusual signs and symptoms.
• Drink alcohol in moderation, if at all. Limit the amount of alcohol you drink to less than one drink a day, if you choose to drink.
• Exercise most days of the week. Aim for at least 30 minutes of exercise on most days of the week. If you haven't been active lately, ask your doctor whether it's OK and start slowly.
• Limit postmenopausal hormone therapy. Combination hormone therapy may increase the risk of breast cancer. Talk with your doctor about the benefits and risks of hormone therapy. Some women experience bothersome signs and symptoms during menopause and, for these women, the increased risk of breast cancer may be acceptable in order to relieve menopause signs and symptoms. To reduce the risk of breast cancer, use the lowest dose of hormone therapy possible for the shortest amount of time.
• Maintain a healthy weight. If your current weight is healthy, work to maintain that weight. If you need to lose weight, ask your doctor about healthy strategies to accomplish this. Reduce the number of calories you eat each day and slowly increase the amount of exercise. Aim to lose weight slowly — about 1 or 2 pounds a week.

Breast cancer prevention for women with a high risk
If your doctor has assessed your family history and other factors and determined that you may have an increased risk of breast cancer, options to reduce your risk include:

• Preventive medications (chemoprevention). Estrogen-blocking medications help reduce the risk of breast cancer. Options include tamoxifen and raloxifene (Evista). These medications carry a risk of side effects, so doctors reserve these medications for women who have a very high risk of breast cancer.
• Preventive surgery. Women with a very high risk of breast cancer may choose to have their healthy breasts surgically removed (prophylactic mastectomy). They may also choose to have their healthy ovaries removed (prophylactic oophorectomy) to reduce the risk of both breast cancer and ovarian cancer.