Breast Cancer
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Incidence (Frequency)
Breast cancer is the most common cancer to affect women. In 2004, about 216,000 new cases of invasive breast cancer were diagnosed in the United States, along with 59,390 new cases of non-invasive breast cancer.
The actual cause of breast cancer is not known, however, the American Cancer Institute suggests that approximately one in every four women will undergo a breast biopsy to evaluate a suspicious breast mass in her lifetime. Of this group, 12% will develop some variant of breast cancer. Five to ten percent of these breast cancers are inherited (genetically passed), 20%-30% will be familial (more common in certain families), and 55%-75% will be sporadic or new cancers that develop spontaneously.
Risk Factor
A tremendous amount of promising research is under way to determine the cause of breast cancer and to establish effective ways to prevent it. Anything that INCREASES your chance of developing breast cancer is called a risk factor.
Anything that REDUCES your risk of developing breast cancer is called a protective factor. Although you can control many risk factors, remember that doing so does not guarantee zero risk. It is also important to keep in mind that many women who have a particular risk factor for breast cancer never develop it.
The first risk factor is hormonal and is due to an increased exposure to the hormone estrogen. This excessive exposure may be because of menarche (menses younger than 12 years old), nulliparity (lack of pregnancy), late menopause (menses stops after age 50), age of first born after the age of 30, five years of combined estrogen/progesterone hormone replacement therapy and lastly obesity.
There are also nonhormonal factors, which may increase the risk of developing breast cancer. It is well documented that increased age causes a higher risk of breast cancer, as well as a positive family history of breast cancer. If the mother or daughter of the patient develops breast cancer, then that individual is probably at a 2-3 times greater risk of developing a breast cancer at a later date. The risk factor, however, decreases in woman with distant relatives who have breast cancer (cousins, aunts, grandmother). Other nonhormonal risk factors are a breast biopsy, which reveals the presence of abnormal cells, or cancer cells found in a previous biopsy. Radiation exposure and excessive alcohol usage are also nonhormonal risk factors for breast carcinoma.
Ways to Reduce the Risk of Breast Cancer
There are no definitive ways to decrease the occurrence of breast cancer; however, the drug tamoxifen has shown promise in decreasing the incidence of breast cancer by 49% in high-risk patients. This drug effectively blocks estrogen receptors, thereby decreasing the estrogen exposure to the individual. Also, prophylactic mastectomy, or removal of the breast before cancer develops, decreases the risk by 90% in high-risk patients.
Diagnosis
There are many ways of diagnosing breast cancer, the most common being self-examination. A second option would be to have a yearly exam by a health professional; these exams occurring every 3 years between the ages of 20-40 and every year after the age of 40. Mammograms, or radiologic evaluation of the breast, are the best available technique for detecting breast carcinoma; however, this technique can miss the presence of a tumor 10% of the time. Currently, most centers recommend yearly mammograms after the age of 40. Genetic testing should be done in coordination with genetic counselors because of the fact that 80% of inherited breast cancers have BRCA-1 or BRCA-2 gene mutation seen in the DNA. Other useful imaging techniques are ultrasound, which is extremely helpful in differentiating solid from fluid lesions, and MRI, which is used as an additional screening method in high-risk patients.
Following the finding of a breast mass on examination or during a mammogram, a biopsy is usually recommended. The goal of the biopsy is to obtain breast tissue that may be examined for malignant features. The various biopsy techniques depend on whether the breast mass can be felt (palpable) or not felt (nonpalpable) on physical examination. For the nonpalpable lesion, the technique involves a stereotactic core biopsy, which uses either a computer or mammogram machine to guide a needle to the biopsy site for examination. The second way to detect or biopsy a nonpalpable lesion is using a wire localized excisional biopsy where a radiologist uses a computer, mammogram, or ultrasound device to place a guidewire by the abnormal area. The surgeon then follows this to the point of the abnormal tissue and then surgically removes the abnormal breast tissue. Both procedures are usually outpatient and under a local anesthetic. If the lesion is palpable, or can be felt, a fine needle aspiration can be performed, or a core biopsy or direct excision of the mass can be done, usually under a local anesthetic on an outpatient basis.
Breast Anatomy
The breast is a gland designed to make milk. The lobules in the breast make the milk, which then drains through the ducts to the nipple. The breast is composed of 15 to 20 of these lobules, which then terminate into major ducts that open up into the nipple.
The Types of Breast Cancer
Noninvasive -
whereby the cancer cells have not invaded surrounding tissue.
The 2 types of noninvasive cancers are:
- Ductal carcinoma in situ - which occurs in 5%-10% of breast cancers, or
- Lobular carcinoma in situ - which occurs in 2%-5% of breast cancers.
Invasive -
whereby the cancer cells have invaded the surrounding tissue.
The 2 types of invasive cancers are:
- Ductal carcinoma - which occurs in 60%-75% of breast cancers, begins in the ducts and is the most common type of breast cancer.
- Lobular carcinoma - which occurs in 10% of breast cancers.
Paget's disease
Squamous carcinoma
The Stages of Breast Cancer
Stage 0
This stage is used to describe non-invasive breast cancer. There is no evidence of cancer cells breaking out of the part of the breast in which it started, or of getting through to or invading neighboring normal tissue. Lobular carcinoma in situ (LCIS) and Ductal carcinoma in situ (DCIS) are examples of Stage 0.
Stage I
This stage describes invasive breast cancer (cancer cells are breaking through to or invading neighboring normal tissue) in which:
- The tumor measures up to two centimeters, AND
- No lymph nodes are involved.
Stage II
This stage describes invasive breast cancer in which:
- The tumor measures at least two centimeters, but not more than five centimeters, OR
- Cancer has spread to the lymph nodes under the arm on the same side as the breast cancer. Affected lymph nodes have not yet stuck to one another or to the surrounding tissues, a sign that the cancer has not yet advanced to stage III. (The tumor in the breast can be any size.)
Stage III
Stage III is divided into subcategories known as III A and III B.
Stage III A
Stage III A describes invasive breast cancer in which:
- The tumor measures larger than five centimeters, OR
- There is significant involvement of lymph nodes. The nodes clump together or stick to one another or surrounding tissue.
Stage III B
This stage describes invasive breast cancer in which:- A tumor of any size has spread to the breast skin, chest wall, or internal mammary lymph nodes (located beneath the breast right under the ribs, inside the middle of the chest).
- Stage III B includes inflammatory breast cancer, a very uncommon but very serious, aggressive type of breast cancer. The most distinguishing feature of inflammatory breast cancer is redness involving part or all of the breast. The redness feels warm. You may see puffiness of the breast's skin that looks like the peel of a navel orange ("peau d'orange"), or even ridges, welts or hives. And part or all of the breast may be enlarged and hard. A lump is present only half of the time. Inflammatory breast cancer is sometimes misdiagnosed as a simple infection.
Stage IV
This stage includes invasive breast cancer in which:
- A tumor has spread beyond the breast, underarm, and internal mammary lymph nodes, AND
- A tumor may have spread to the supraclavicular lymph nodes (nodes located at the base of the neck, above the collarbone), lungs, liver, bone, or brain.
- Metastatic at presentation means that the breast cancer has spread beyond the breast and nearby lymph nodes, even though this is the first diagnosis of breast cancer. The reason for this is that the primary breast cancer was not found when it was only inside the breast. Metastatic cancer is considered stage IV.
Additional staging information
You may also hear terms such as "early" or "earlier" stage, "later" or "advanced" stage breast cancer. Although these terms are not medically precise (they may be used differently by different doctors), here is a general idea of how they apply to the official staging system:
Early stage
Later stage
- (stage II if there are many lymph nodes involved)
- Stage III (IIIA, IIIB)
Advanced stage:
You may also hear the cancer described by three characteristics:
- Size (T stands for tumor),
- Node involvement (N stands for node), and
- Whether it has metastasized (M stands for metastasis).
The T category describes the original (primary) tumor:
- TX means the tumor can't be measured or found.
- T0 means there isn't any evidence of the primary tumor.
- Tis means the cancer is "in situ" (the tumor has not started growing into the breast tissue).
- The numbers T1-T4 describe the size and/or how much the cancer has grown into the breast tissue. The higher the T number, the larger the tumor and/or the more it may have grown into the breast tissue.
The N category describes whether or not the cancer has reached nearby lymph nodes:
- NX means the nearby lymph nodes can't be measured or found.
- N0 means nearby lymph nodes do not contain cancer.
- The numbers N1-N3 describe the size, location, and/or the number of lymph nodes involved. The higher the N number, the more the lymph nodes are involved.
The M category tells whether there are distant metastases (whether the cancer has spread to other parts of body):
- MX means metastasis can't be measured or found.
- M0 means there are no distant metastases.
- M1 means that distant metastases were found.
Once the pathologist knows your T, N, and M characteristics, they are combined, and an overall "stage" of 0, I, II, III, III A, III B, or IV is assigned.
For example, a T1, N0, M0 breast cancer would mean that the primary breast tumor:
- is less than two centimeters across (T1),
- does not have lymph node involvement (N0), and
- has not spread to distant parts of the body (M0).
This cancer would be grouped as a stage I cancer
The Treatment of Breast Cancer
Local treatment refers to anything that is targeted to a specific area of the body—such as the breast, the lymph nodes, the lungs—as opposed to the whole body. Treatment to the lymph nodes near the breast is also sometimes referred to as "regional" treatment, because the nodes lie in the region surrounding the breast.
The whole breast can be treated by mastectomy or breast preservation therapy:
- Mastectomy involves removal of the entire breast. Mastectomy may be followed by radiation to the area where the breast used to be.
- Breast preservation therapy removes the breast cancer by lumpectomy (also called "wide resection," "partial mastectomy," or "quadrantectomy") and is also followed by radiation to the remainder of the breast tissue.
These two options are considered equally effective for women with a breast cancer measuring about four centimeters or less. For women with a single tumor larger than about four centimeters, breast preservation therapy may still be an option if chemotherapy is able to shrink the cancer substantially BEFORE surgery.
Sequence of Treatment
Your team of doctors will most likely recommend a particular sequence of treatment. Here is the most common "pathway":
- Usually surgery is first.
- If chemotherapy is going to be part of your care, it often goes second.
- Radiation usually follows surgery and chemotherapy (when chemotherapy is given).
- Tamoxifen or other hormonal (anti-estrogen) therapy is most commonly started after the other treatments have been given.
There are many exceptions to this sequence, however. For women with stage III or IV disease, chemotherapy may be given first to shrink large tumors and address cancer in the rest of the body, before major surgery. Some centers or clinical studies give chemotherapy and radiation together (not separately). There are also many other variations in timing and sequence.
Following the above noted procedures, an oncologist would then advise patients of the options for further treatment after surgery is completed. This is usually based on the stage of the disease.
A new technique called a sentinel lymph node biopsy has been developed to help locate the lymph nodes during surgery. This technique is based on using a radioactive material, or blue dye, injected into the breast prior to surgery. The surgeon then uses the uptake of this radioactive dye to identify the lymph nodes during surgery that may be suspicious for containing the spreading cancer. This helps guide the surgeon to the most likely node that may harbor cancer, thereby allowing him to biopsy these for the evaluation of cancer spread. This procedure is helpful in that it limits the more aggressive armpit dissection, which may be required, and it lowers postoperative complications like nerve injury and arm swelling.
Breast Reconstruction Options
Whatever your age, marital status, sexual activity or orientation, you can't predict how you will react to the loss of a breast. How important is re-creating your breast to you? Can you live with "take-off-and-put-on" alternatives? Do you need surgical breast reconstruction to feel whole, again? What about timing? The Breast Reconstruction section of the Breast Restorative Center helps you understand your options AND sort through the medical and personal issues you should consider.
Detailed description is in the Breast Reconstruction section of the Restorative Breast Center
CLICK ON THE LINKS BELOW TO VIEW AN ANIMATION OF THE PROCEDURE:
Recovery after Breast Cancer
Nutrition
Giving your body the nutrients it needs—is important for everyone. When combined with exercising and maintaining a healthy weight, eating well is an excellent way to help your body stay strong and healthy. Current research findings suggest that physical activity, a healthy diet, and a healthy weight can help reduce the risk of getting breast cancer for the first time or having a breast cancer come back. A healthy diet—one with a variety of foods that includes lots of fruits and vegetables and regular protein—gives you the reserve of nutrients you need to keep your strength up while you're fighting breast cancer. These reserves also help rebuild your body's tissues and keep your immune system strong to help fight off infection. Plus, a healthy diet can help you cope with treatment side effects. There is evidence that some cancer treatments actually work better in people who are eating enough calories and protein. While you're having breast cancer treatment, it's more important than ever that you eat a healthy diet.
Arm Lymphedema
Lymph edema (pronounced lim-fe-DEE-ma) is a side effect that can begin during or after breast cancer treatment. It isn't life threatening, but it can last over a long period of time. This condition involves swelling of the soft tissues of the arm or hand. The swelling may be accompanied by numbness, discomfort, and sometimes infection.
There's no reliable way to find out your level of risk for lymphedema, but by taking proper precautions you CAN greatly reduce your chances of developing this complication. Lymphedema of the arm is an accumulation of lymph fluid in the soft tissues of the arm, with accompanying swelling (also called edema). To understand how it happens, you have to know a little bit about how blood and lymphatic fluid move around your body. You can think of lymphedema as a plumbing problem: Veins and lymphatic channels are like pipes and drains that can handle the normal load of lymphatic fluid. If lymph nodes and channels are removed, there might not be enough pipes and drains to handle all the fluid. Some women have mild lymphedema, which is hardly noticeable. Some develop moderate lymphedema that may be noticeable, tends to persist, and gets worse when aggravated. Others have severe lymphedema that is very uncomfortable and even disabling. For all of these cases, there are treatments that can help ease the discomfort and reduce the swelling.
Ways to Avoid Lymphadema. Prevention is the best tool against arm lymphedema. Learn the warning signs and the precautions to take. Make these guidelines and a heightened awareness a regular part of your life. Skin care is your first line of defense. Since the skin acts as a barrier to infection, any disruption of the skin can spell trouble. Burns, chafing, dryness, cuticle injury (such as hangnails), cracks, cuts, splinters, and insect bites are immediate risks for infection.
Pain
For women affected by breast cancer, overcoming pain can be a major part of dealing with the disease and its treatment. Pain is a common side effect of treatment and also a side effect of cancer, however there are ways to manage the pain. Consult your physician if your pain continues to limit your daily activity.
Understanding Your Immune System
The immune system responds immediately when your body encounters any threat, such as a virus or injury. In response to such threats, the immune system produces a generalized, non-specific reaction known as inflammation. This response is like an army artillery attack: Shells burst all over, damaging and killing all varieties of bacteria, viruses, and other microorganisms that happen to be in range—including some of the body's own cells.
Understanding Fatigue
If you're in the midst of breast cancer treatment, your body is in a war against cancer. It needs all its resources to fight the disease, so it shuts down your energy for other activities that would take away your strength from the battle. Fatigue is the result.
Staying Informed
Even many years after your initial treatment is over, you should be checked regularly so your doctors can monitor your health and make sure you're continuing to do well. If you're taking hormonal therapy or any other long-term treatment, you'll also want to check in with your doctor to monitor any side effects.
Another important way to take care of yourself in the long term, and another reason to keep in touch with your doctor, is to stay informed about new treatment developments. Thanks to ongoing research by experts all over the world, breakthroughs in breast cancer treatment are happening all the time. It's always possible that a new advance can help you stay strong and healthy long into the future.
Myths about Breast Cancer
1. Breast cancer only affects older women.
No.
While it's true that the risk of breast cancer increases as we grow older, breast cancer can occur at any age. From birth to age 39, one woman in 231 will get breast cancer (<0.5% risk); from age 40–59, the chance is one in 25 (4% risk); from age 60–79, the chance is one in 15 (nearly 7%).
2. If you have a risk factor you will definitely develop breast cancer.
No.
Getting breast cancer is not a certainty, even if you have one of the stronger risk factors, like a breast cancer gene abnormality. Of women with a BRCA1 or BRCA2 inherited genetic abnormality, 40–80% will develop breast cancer over their lifetime; 20–60% won't. All other risk factors are associated with a much lower probability of being diagnosed with breast cancer.
3. If breast cancer doesn't run in your family, you won't get it.
No.
Every woman has some risk of breast cancer. About 80% of women who get breast cancer have no known family history of the disease. Increasing age – just the wear and tear of living – is the biggest single risk factor for breast cancer. For those women who do have a family history of breast cancer, your risk may be elevated a little, a lot, or not at all. If you are concerned, discuss your family history with your physician or a genetic counselor.
4. The use of antiperspirants contributes to an increased risk of developing breast cancer.
No.
There is no evidence that the active ingredient in antiperspirants or reducing perspiration from the underarm area, influences breast cancer risk. The supposed link between breast cancer and antiperspirants is based on misinformation about anatomy and a misunderstanding of breast cancer.
5. The use of birth control pills can lead to an increased risk of developing breast cancer.
No.
Modern day birth control pills contain a low dose of the hormones estrogen and progesterone. They have not been associated with an increased risk of breast cancer. The higher-dose contraceptive pills used in the past were associated with a small increased risk in only a few studies. Today's birth control pills can provide some protection against ovarian cancer.
6. Eating fatty foods can increase your risk of breast cancer.
No.
Several large studies have not been able to demonstrate a clear connection between eating high-fat foods and a higher risk of breast cancer. Ongoing studies are attempting to clarify this issue further. We can say that avoidance of high-fat foods is a healthy choice for other reasons: to lower the "bad" cholesterol (low-density lipoproteins), increase the "good" cholesterol (high-density lipoproteins); to make more room in your diet for healthier foods, and to help you control your weight. Excess body weight, IS a risk factor for breast cancer, because the extra fat increases the production of estrogen outside the ovaries and adds to the overall level of estrogen in the body. If you are already overweight, or have a tendency to gain weight easily, avoiding high-fat foods is a good idea.
7. A monthly breast self-exam is the best way to diagnose breast cancer.
No.
High quality, film-screen mammography is the most reliable way to find breast cancer as early as possible, when it is most curable. By the time a breast cancer can be felt, it is usually bigger than the average size of a cancer first found on mammography. Breast examination by you or your healthcare provider is still very important. About 25% of breast cancers are found only on breast examination (not on the mammogram), about 35% are found on mammography alone, and 40% are found by both physical exam and mammography. Keep both bases covered.
8. I'm at high risk for breast cancer and there's nothing I can do about it.
No.
There are several effective ways to reduce—but not eliminate—the risk of breast cancer in women at high risk. Options include lifestyle changes (minimize alcohol consumption, stop smoking, exercise regularly), medication (tamoxifen, also called Nolvadex); and in cases of very high risk, surgery may be offered (prophylactic mastectomies, and for some women, prophylactic ovary removal). Be sure that you have consulted with a physician or genetic counselor before you make assumptions about your level of risk.
Risks
There is a potential for complications in any operative procedure. The most common being infection, scarring and sensation changes. During your consultation a detailed discussion of these potential risks will be given to you.
Related Links/Resources
- Nationwide, community-based, voluntary health organization dedicated to eliminating cancer as a major health problem through research, education, advocacy and service
- Public Health Institute site that offers a unique collection of artwork and personal stories from over 50 breast cancer survivors, their families, and friends. Project's aim is to raise awareness about the disease, and to support and empower the public.
- It is a year-long project devoted to the topic of breast cancer at KBOO-FM under the direction of award-winning producers Dmae Roberts of MediaRites and Barbara Bernstein of the Media Project.
- Since 1996, The Breast Cancer Research Foundation has raised over $1 million for research at the UAB Comprehensive Cancer Center in Birmingham, Alabama. Majority of these funds are raised through an annual golf event featuring LPGA professionals. For more information, please call (205) 871-GOLF.
- CancerCare is a national non-profit organization whose mission is to provide free professional help to people with all cancers through counseling, education, information and referral and direct financial assistance.
- Non-profit educational organization committed to empowering all women affected by breast cancer to live as long as possible with the best quality of life. Programs include educational conferences, a quarterly newsletter, outreach to medically under-served women, consumer focused booklets, the Paula A. Seidman Library and Resource Center, Young Survivors group, and a Survivors' Helpline.
- A resource on breast health information for patients and health care professionals.
- A national nonprofit organization founded in March 1995. The free support services provided by this organization are designed to give emotional support to mothers who have daughters battling breast cancer.
- The NBCC is a grassroots effort in the fight against breast cancer. In 1991, the Coalition was formed with one mission, to eradicate breast cancer through action and advocacy.
- The only patient-led advocacy group representing this nation's 8.2 million cancer survivors. Our mission is to assure quality cancer care for all Americans.
- Provides information on the prevention and management of lymphedema and supports research into the causes and possible alternative treatments for this condition.
- Provides support and information to anyone who has been touched by breast cancer.
- A national non-profit that focuses on the unique issues and challenges faced by women 40 and younger diagnosed with breast cancer. These issues and challenges include higher mortality rates, early menopause, pregnancy after diagnosis, a more aggressive disease and a lack of clinical trials for young women. Through action, advocacy and awareness, the YSC reaches at-risk women, young breast cancer survivors and the medical community, letting them know that young women CAN and DO get breast cancer.
Glossary
