Breast
Cancer Symptoms
Breast cancer may or may not cause
symptoms. Some women may discover the problem themselves, while others may have
the abnormality first detected on a screening exam. Common breast cancer
symptoms include the following:
- Non-painful lumps or masses
- Lumps or swelling under the arms
- Nipple skin changes or discharge
- Noticeable flattening or indentation of the breast
- Change in the nipple
- Unusual discharge from the nipple
- Changes in the feel, size, or shape of the breast
tissue
Types of Breast Cancer
Inflammatory
Breast Cancer
Inflammatory breast cancer is a rare type of
cancer that often does not cause a breast lump or mass. As seen in this photo,
it often causes thickening and pitting of the skin, like an orange peel. The
affected breast may also be larger or firmer, tender, or itchy. A skin rash or
reddening of the skin is common. These changes are caused by cancer cells
blocking lymph vessels in the skin. Inflammatory cancer of the breast typically
has a fast growth rate.
Invasive Ductal
Carcinoma
Invasive (or infiltrating) ductal carcinoma
(IDC) is the most common type of breast cancer. About 80% of all breast cancers
are invasive ductal carcinomas. Invasive ductal carcinoma refers to cancer that
has broken through the wall of the milk ducts and has invaded the breast
tissues. Invasive ductal carcinoma can spread to the lymph nodes and possibly
to other areas of the body.
Ductal Carcinoma
in Situ (DCIS)
Ductal carcinoma in situ (DCIS) is considered
to be a non-invasive or pre-invasive breast cancer. Ductal means that the
cancer starts inside the milk ducts, carcinoma refers to any cancer that starts
in the skin or other tissue (including breast tissue) that line or cover the
internal organs, and in situ means “in its original place.” The difference
between DCIS and invasive cancer is that in DCIS, the cells have not spread
through the walls of the milk ducts into the surrounding breast tissue.. DCIS
is considered a ‘pre-cancer’, but some cases can transform into more invasive
cancers.
Invasive Lobular
Carcinoma
Invasive (or infiltrating) lobular carcinoma
(ILC) is the second most common type of breast cancer after invasive ductal
carcinoma. Lobular means that the cancer started in the milk-producing lobules,
which empty out into the ducts that carry milk to the nipple. Invasive lobular
carcinoma refers to cancer that has broken through the wall of the lobule and
begun to invade the breast tissues. Invasive lobular carcinoma can spread to
the lymph nodes and possibly to other areas of the body.
Mucinous
Carcinoma
Mucinous (or colloid) carcinoma of the breast
is a rare form of invasive ductal carcinoma. In this type of cancer, the tumor
is composed of abnormal cells that “float” in pools of mucin, part of the
slimy, slippery substance known as mucus. Mucus lines most of the inner surface
of our bodies, such as our digestive tract, lungs, liver, and other vital
organs. Breast cancer cells can produce some mucus. In mucinous carcinoma,
mucin becomes part of the tumor and surrounds the breast cancer cells.
“Pure” mucinous carcinomas make up only 2-3%
of invasive breast cancers. Approximately 5% of invasive breast cancer tumors
have a mix of mucinous components in addition to other types of breast cancer
cells.
Triple-Negative
Breast Cancers
Testing negative for estrogen receptors
(ER-), progesterone receptors (PR-), and HER2 (HER2-) on a pathology report
means the cancer is “triple-negative”. These negative results indicate the
growth of the cancer is not supported by the hormones estrogen and
progesterone, nor by the presence of too many HER2 receptors. Therefore,
triple-negative breast cancer does not respond to hormonal therapy (such as
tamoxifen or aromatase inhibitors) or therapies that target HER2 receptors,
such as Herceptin. However, other medicines can be used to treat
triple-negative breast cancer.
Paget’s Disease
of the Nipple
Paget's disease of the nipple is a rare form
of breast cancer in which cancer cells collect in or around the nipple. The
cancer usually affects the ducts of the nipple first then spreads to the nipple
surface and the areola. A scaly, red, itchy, and irritated nipple and areola
are signs of Paget’s disease of the nipple. One theory for the cause of Paget’s
disease is that the cancer cells start growing inside the milk ducts within the
breast and then break through to the nipple surface. Another possibility is
that the cells of the nipple itself become cancerous.
Causes of Breast Cancer
Certain genes control the life cycle—the
growth, function, division, and death—of a cell. When these genes are damaged,
the balance between normal cell growth and death is lost. Normal breast cells
become cancerous because of changes in DNA structure. Breast cancer is caused
by cellular DNA damage that leads to out-of-control cell growth.
Causes of Breast
Cancer: Genetics & Mutations
Inherited genes can increase the likelihood
of breast cancer. For example, mutations of genes BRCA1 and BRCA2 (linked to an
increased risk of breast and ovarian cancers) can inhibit the body’s ability to
safe-guard and repair DNA. Copies of these mutated genes can be passed on
genetically to future generations, leading to a genetically-inherited increased
risk of cancer.
Causes of Breast
Cancer: Environment
Breast cancer may be caused by environmental
exposure. Sunlight can cause DNA damage that leads to breast cancer through
ultraviolet radiation. So can air pollutants like soot, wood dust, asbestos,
and arsenic, to name just a few.
Causes of Breast
Cancer: Lifestyle
Lifestyle choices can lead to breast cancer
as well. Eating a poor diet, inactivity, obesity, heavy alcohol use, tobacco
use including smoking, and exposure to chemicals and toxins are all associated
with a greater breast cancer risk.
Causes of Breast
Cancer: Medical Treatment
Medical treatment with chemotherapy,
radiation, or immunosuppressive drugs used to decrease the spread of cancer
throughout the body can also cause damage to healthy cells. Some “second
cancers”, completely separate from the initial cancer, have been known to occur
following aggressive cancer treatments.
Mammograms and Breast Cancer Prevention
Early detection of breast cancer is the key
to survival. Mammograms are X-rays of the breast that can detect tumors at a
very early stage, before they would be felt or noticed otherwise. During a
mammogram, your breasts are compressed between two firm surfaces to spread out
the breast tissue. Then an X-ray captures black-and-white images of your
breasts that are displayed on a computer screen and examined by a doctor who
looks for signs of cancer. Women at average risk have are recommended to have a
mammogram every year starting at age 45. Starting at age 54, women are
recommended to have a screening mammogram every 2 years as long as they remain
healthy.
3D mammograms, or breast tomosynthesis, is a
breast imaging procedure that also uses X-rays to produce images of breast
tissue in order to detect abnormalities.
Breast Cancer Prevention: Breast MRI and
Ultrasound
Breast MRI
MRI (magnetic resonance imaging) is a
technology that uses magnets and radio waves to create detailed, 3D images of
the breast tissue. Before the test you may be injected through an intravenous
line, in the arm, with a contrast solution (dye). The contrast solution will
allow potential cancerous breast tissue to show more clearly. Radiologists are
able to see areas that could be cancerous because the contrast tends to be more
concentrated in areas of cancer growth.
During a breast MRI the breasts are exposed
as the patient lies flat on a padded platform with cushioned openings for the
breasts. A breast coil surrounds each opening and works with the MRI unit to
create the images. MRI imaging is a painless diagnostic tool. The test takes
between 30 and 45 minutes.
Breast Cancer Prevention: Breast Self-Exams
Experts recommend that women be aware of
their breasts and notice any changes, rather than performing checks on a
regular schedule. Women who choose to do self-exams should be sure to discuss
the technique with their doctor.
What is a Breast
Self-Exam?
A breast self-exam is a way to check your
breasts for changes such as lumps or thickenings. Early breast cancer detection
can improve your chances of surviving the disease. Any unusual changes
discovered during the breast self-exam should be reported to your doctor.
Lump in Breast: Could it be Cancer?
Remember that the majority (about 80%) of
breast lumps are not due to cancer. Cysts, benign tumors, or changes in
consistency due to the menstrual cycle can all cause benign breast lumps.
Still, it's important to let your doctor know about any lumps or changes in
your breast that you find.
Breast Cancer Biopsy
A biopsy is the most certain way to determine
whether a breast lump is cancerous. Biopsies may be taken through a needle or
through a minor surgical procedure. The results can also determine the type of
breast cancer that is present in many cases (there are several different types
of breast cancers). Treatments are tailored to the specific type of breast
cancer that is present.
Needle Biopsies
A needle biopsy uses a hollow needle to
remove tissue or cell samples from the breast. A pathologist studies the
samples under a microscope to see if they contain cancer. There are two types
of needle biopsies: core need biopsy and fine needle aspiration (fine needle
biopsy).
1.
Core Needle Biopsy
If a lump can be
felt in the breast (palpable mass), a core needle biopsy may be performed. The
doctor will use a small amount of local anesthetic to numb the skin and the
breast tissue around the area. The doctor will insert the needle and remove a
small amount of tissue to be examined.
2.
Ultrasound-Guided Core Needle Biopsy
This is one type of
biopsy for lumps or abnormalities that cannot be felt (nonpalpable mass). A
core needle is placed into the breast tissue and ultrasound helps confirm the
exact location of the potential cancer so the needle is placed correctly.
Tissue samples are then taken through the needle. Ultrasound can see the
difference between cysts and solid lesions.
3.
MRI-Guided Core Needle Biopsy
For this test, you
will be given a contrast agent through an IV. Your breast will be numbed and
compressed and several MRI images will be taken. The MRI images will guide the
doctor to the suspicious area. A needle will be used in the biopsy device to
remove tissue samples with a vacuum assisted probe.
4.
Stereotactic Biopsy
If the lump is
nonpalpable you could be also given a stereotactic biopsy. Using a local
anesthetic, the radiologist makes a small opening in the skin. A needle is
placed into the breast tissue, and imaging studies help confirm the exact
placement. Tissue samples are taken through the needle.
Surgical
Biopsies
A surgeon makes a cut (incision) in the
breast to remove tissue.
1.
Open Excisional Biopsy
This surgery removes
an entire lump and the issue is examined under a microscope. If a section of
normal breast tissue is taken all the way around a lump, it is called a
lumpectomy. In this procedure, a wire is put through a needle into the area to
be biopsied. The X-ray helps to make sure it is in the right location and a
small hook at the end of the wire keeps it in position. The surgeon uses the
wire as a guide to locate the suspicious tissue.
2.
Incisional Biopsy
An incisional biopsy
is very similar to an excisional biopsy, but less tissue is removed. Local
anesthetic will be used and you will also get IV sedation. An incisional biopsy
removes part of the tumor, which means that more surgery may be needed to
remove the remaining cancer.
Biopsy Results: Hormone-Sensitive Breast
Cancer
A biopsy can tell whether the breast cancer
has receptors for estrogen (ER-positive) and/or progesterone (PR-positive),
indicating which hormone stimulates tumor growth. About two-thirds of breast
cancers are hormone receptor-positive. Medications can be given that act to
help prevent growth of the tumor from stimulation by these hormones.
ER-positive breast cancer is sensitive to
estrogen, whereas PR-positive breast cancer is sensitive to progesterone. Both
ER-positive and PR-positive breast cancers may respond to hormone therapy.
Hormone receptor (HR) negative is a type of cancer that does not have hormone
receptors and will not be affects by hormone blocking treatments.
Biopsy
Results: HER2-Positive Breast Cancer
HER-2 (human epidermal growth factor
receptor 2) is a protein that is expressed at a high level by about 20% of
breast cancers. Having this receptor means the cancer tends to grow and spread
faster than other forms of breast cancer. There are special targeted treatments
available for this type of tumor.
Treatments specifically for
HER2-positve breast cancer include:
- Herceptin (trastuzumab)
- Kadcyla (ado-trastuzumab emtansine)
- Perjeta (pertuzumab)
- Tykerb (lapatinib)
Breast Cancer Stages
Breast cancer stages are classified according
to cancer tumor size, location, and extent of spread. Staging helps doctors
determine the prognosis and treatment for cancer. The TNM staging system
classifies breast cancers according to:
- Tumor (T):
Primary tumor size and/or extent
- Nodes (N):
Spread of cancer to lymph nodes in the regional area of the primary tumor
- Metastasis
(M): Spread of cancer to distant sites away from the primary tumor
TNM Breast
Cancer Classification
The TNM classification of a cancer usually
correlates to one of the following five stages:
- Stage 0
Breast Cancer (Tis, N0, M0): This refers to cancer that is "in
situ," meaning that cancerous cells are confined to the breast. This
type of breast cancer has not spread and is not invading other tissues.
- Stage I
Breast Cancer: Stage I invasive breast cancer is broken up into
subcategories known as IA and IB.
- Stage IA
breast cancer (T1, N0, M0) refers to the tumor measuring up to 2
centimeters and no cancer has spread outside the breast.
- Stage IB
breast cancer (T0 or T1, N1mi, M0) includes no tumor in the breast, but
small groups of cancer cells in the lymph nodes. Stage IB could also be a
tumor in the breast that is no larger than 2 centimeters and small groups
of cancer cells in the lymph nodes.
Stage II Breast
Cancer
Stage II invasive breast cancer is broken up
into two subcategories known as IIA and IIB.
- Stage IIA
breast cancer (T0 or T1 or T2, N0 or N1, M0) includes no tumor in the
breast, but cancer (larger than 2 millimeters) in 1 to 3 axillary lymph
nodes or lymph nodes near the breast bone. Stage IIA can also include a
tumor measuring 2 centimeters or smaller and cancer has spread to the
axillary lymph nodes or a tumor 2-5 centimeters that has not spread to the
axillary lymph nodes.
- Stage IIB
breast cancer (T2 or T3, N0 or N1, M0) refers to a tumor 2-5 centimeters
and small groups (0.2-2.0 millimeters) of breast cancer cells in the lymph
nodes or a tumor 2-5 centimeters with cancer in 1 to 3 axillary lymph
nodes or lymph nodes near the breastbone. Stage IIB breast cancer can also
include a tumor larger than 5 centimeters with no affected lymph nodes.
Stage III Breast
Cancer
Stage III invasive breast cancer is broken up
into subcategories IIIA, IIIB, and IIIC.
- Stage IIIA
(T0 to T3, N1 or N2, M0) refers to the tumor ranging from nonexistent to
any size and cancer is found in 4 to 9 axillary lymph nodes or in lymph
nodes near the breastbone. Stage IIIA can also include a tumor larger than
5 centimeters with small groups of breast cancer cells (0.2 to 2
millimeters) in the lymph nodes or a tumor larger than 5 centimeters with
cancer in 1 to 3 axillary lymph nodes or lymph nodes near the breastbone.
- Stage IIIB
(T4, N0 to N2, M0) refers to a tumor of any size and has spread to the
chest wall and/or skin of the breast in addition to cancer that has spread
to up to 9 axillary lymph nodes or lymph nodes near the breastbone.
- Stage IIIC
(any T, N3, M0) refers to a tumor of any size and possible spreading to
the chest wall and/or the skin of the breast as well as the cancer in 10
or more axillary lymph nodes or spread to lymph nodes above or below the
collarbone or near the breastbone.
- Stage IV
Breast Cancer (any T, any N, M1): Stage IV breast cancer refers to breast
cancer that has spread to other organs such as the lungs, distant lymph
nodes, skin, bones, liver, or brain.
Breast Cancer Survival Rates
Breast cancer survival depends upon a number
of factors. Cancers that are found early are often localized to the breast.
Statistics on the survival rate of breast cancer are often given as 5-year
survival rates. The 5-year survival rate is the percentage of people who live
at least 5 years after being diagnosed with breast cancer. According to the American
Cancer Society, women with early stage (stage 1) breast cancer have a 5-year
survival rate of 100%. Women with breast cancer that has spread to distant
sites in the body (stage 4) have only a 20% chance of surviving 5 years; but
this rate can improve as treatment advances are made.
Breast Cancer Treatments: Surgery
Breast-conserving surgery removes the cancer
and some healthy tissue around it, but not the breast. Some lymph nodes under
the arms may be removed for biopsy. If the cancer is near the chest wall, part
of it may be removed. Breast-conserving surgery is also known as breast-sparing
surgery, lumpectomy, partial mastectomy, quadrantectomy, and segmental
mastectomy.
Mastectomy
Mastectomy is the removal of the entire
breast and all the surrounding tissue and possibly nearby tissues. There are
different mastectomy surgeries available, depending on how much additional
tissue is removed. The following are different types of mastectomies:
- Simple
mastectomy includes removal of the entire breast, but does not remove
lymph nodes or muscle tissue.
- Double
mastectomy is when both breasts are removed.
- Skin-sparing
mastectomy includes keeping the skin over the breast intact. Breast
reconstruction surgery is typically planned immediately after the
mastectomy.
- Nipple-sparing
mastectomy keeps the breast skin and nipple intact and breast
reconstruction surgery immediately follows.
- Modified
radical mastectomy combines a simple mastectomy with the removal of the
lymph nodes under the arm
- Radical
mastectomy includes the removal of the entire breast, lymph nodes, and the
pectoral muscles under the breast.
Breast Cancer Treatments: Radiation Therapy
High-energy beams of localized radiation are
used to kill targeted cancer cells. Radiation therapy can be used after breast
cancer surgery, or it may be used in addition to chemotherapy for widespread
cancer. This treatment does have side effects, which can include swelling of
the area, tiredness, or a sunburn-like effect. There are two ways to administer
radiation therapy.
External Beam
Radiation
A beam of radiation is focused onto the
affected area by an external machine. The treatment is usually given five days
a week for five to six weeks.
Brachytherapy
This form of radiation involves radioactive
seeds or pellets that are implanted into the breast next to the cancer.
Breast Cancer Treatments: Chemotherapy
Chemotherapy drugs are given to kill cancer
cells that are located anywhere in the body. It can be administered by a slow
IV infusion, by pill, or by a brief IV injection, depending upon the drug.
Sometimes chemotherapy is given after surgery to help prevent the cancer from
recurring (adjuvant therapy). Side effects of chemotherapy can include an
increased risk of infection, nausea, fatigue, and hair loss.
Chemotherapy drugs are given to kill cancer
cells that are located anywhere in the body. It can be administered by a slow
IV infusion, by pill, or by a brief IV injection, depending upon the drug.
Sometimes chemotherapy is given after surgery to help prevent the cancer from
recurring. Usually, chemotherapy drugs are given in cycles with certain
treatment intervals followed by a period of rest. The cycle length and rest
intervals differ from drug to drug.
Adjuvant
Chemotherapy
If all visible cancer has been removed, there
is still the possibility that cancer cells have broken off or are left behind.
Adjunct chemotherapy is given to assure that these small amounts of cells are
killed. Since some women have a very low risk of recurrence even without
chemotherapy, it is not given in all cases.
Neoadjuvant
Chemotherapy
Neoadjuvant chemotherapy is given before
surgery. There is no correlation between neoadjuvant chemotherapy and long-term
survival, but there are advantages to see if the cancer responds to the
chemotherapy before surgical removal. This can also reduce the size of the
cancer and allow for a less extensive surgery in some patients.
Chemotherapy for
Advanced Breast Cancer
Chemotherapy can be used if the cancer has
metastasized to distant sites in the body. In this case, doctors will determine
the most appropriate treatment.
Chemotherapy
Side Effects
Different drugs cause different side effects.
Certain types of chemotherapy have specific side effects, but each patient’s
experience is different. The following are common side effects of chemotherapy:
- Fatigue
- Pain
(headaches, muscle pain, stomach pain, and pain from nerve damage)
- Mouth and
throat sores
- Diarrhea
- Nausea and
vomiting
- Constipation
- Blood
disorders
- Changes in
thinking and memory
- Sexual and
reproductive issues
- Appetite
loss
- Hair loss
- Permanent
damage to the heart, lung, liver, kidneys, or reproductive system
Breast Cancer - Hormone Therapy
Some breast cancer cells are activated by
female hormones estrogen and/or progesterone (ER- and PR-positive breast cancers).
Hormone therapy can stop or slow the growth of hormone receptor-positive tumors
by blocking the cancer cells from receiving the hormones they need to grow.
Hormone therapy is usually given after surgery, but it can also be given to
reduce the chance of developing breast cancer in women at high risk.
Targeted Drug Therapies for Breast Cancer
Targeted therapies are newer treatments for
breast cancer patients. They utilize specific proteins within cancer cells,
like the HER-2 protein. Targeted therapies can stop the HER-2 protein from
stimulating tumor growth in cancer cells that have this protein. Targeted
therapies have fewer side effects than traditional chemotherapy because they
only target cancer cells. They are often used in combination with chemotherapy.
Breast Cancer Recovery
Breast cancer treatment can be both
physically and emotionally exhausting. There are many changes taking place that
may be difficult to cope with. “Chemobrain” is a term coined to describe the
mental changes caused by chemotherapy treatment. Patients have experienced
memory deficits and the inability to focus. Breast cancer treatments can also
leave patients fatigued, which is normal.
It can be difficult to keep up with
activities of daily life, and make patients feel isolated or overwhelmed.
Friends and family can be invaluable sources of support and assistance during
this time. Some people choose to join a local or an online support group to
share their experiences and spread breast cancer awareness.
Breast Reconstructive Surgery
Many women opt to have reconstructive surgery
after breast cancer surgery. Reconstructive procedures use implants or tissues
obtained from other locations in the body. These procedures can be done at the
time of mastectomy, or they may be performed months or even years later.
Implants
A tissue expander will be inserted un the
skin, for a few weeks, to stretch the skin and allow a silicone-gel or saline
implant to be inserted. Each week preceding the implant insertion, the tissue
expander is filled to a desired volume until the patient is satisfied with
their new breast size.
Tissue Flap
Procedure
A women’s own tissue is taken from the
abdomen or back to create a mound to reconstruct the breast. The tissue is
sometimes kept attached to its original blood supply or it is disconnected and
reconnected to a blood supply near the new location. Some patients also have
nipple reconstruction, which is created using tissue from the back or abdomen
flap. The nipple is then tattooed in order to resemble the color of a nipple. A
prosthetic nipple is also an option and can be created by making a copy of your
natural nipple.
Alternative to Reconstructive Surgery:
Prosthesis
A prosthesis, or breast form, is an
alternative to reconstructive surgery. A prosthesis offers the appearance of
breasts without surgery. This is a device that is worn inside a bra or bathing
suit to permit a balanced appearance when clothed. Breast prostheses come in
many shapes, sizes, and materials (silicone gel, foam, or fiberfill interior).
Breast prosthetic devices are often covered by insurance plans.
Is Breast Cancer Genetic?
Breast cancer occurs in both men and women,
but it is about 100 times more likely to affect women than men. Women over age
55 and those with a close relative who have had the condition are at greatest
risk for developing breast cancer. Still, up to 80% of women who do get breast
cancer do not have a relative with the disease. Certain inherited genetic
mutations dramatically increase a women’s risk of breast cancer. The most
common of these are genes known as BRCA1 and BRCA2. Women who inherit mutations
in these genes have up to an 80% chance of developing breast cancer.
The
Breast Cancer (BRCA) Gene Test
Several tests are available to look
for the Breast Cancer (BRCA) gene. A blood test can be given to analyze DNA
mutations in BRCA1 and BRCA2. Women who have inherited mutations have a much
higher risk of developing breast cancer. The BRCA test is typically only
offered to people who may have inherited the mutation. You may be a candidate
for the BRCA gene test if you have the following:
- Personal history of breast cancer
- Personal history of ovarian cancer
- Family history of breast cancer in parents, siblings,
and/or children
- A male relative with breast cancer
- A family member with both breast and ovarian cancers
- A family member with bilateral breast cancer
- Two or more relatives with ovarian cancer
- A relative with known BRCA1 or BRCA2 mutation
- Ashkenazi Jewish ancestry with a close relative with
breast or ovarian cancer
- Ashkenazi Jewish ancestry and a personal history of
ovarian cancer
Breast Cancer Prevention
Factors that can raise the risk of getting
breast cancer include not getting enough exercise, drinking more than one
alcoholic drink per day, and being overweight. Breast cancer prevention also
includes avoiding exposure to carcinogens, chemicals, and radiation from
medical imaging. Some kinds of hormone therapy and birth control pills can also
elevate risk, but the risk returns to normal after stopping these medications.
Some studies have shown that regular physical activity may help lower the risk
of recurrence in women who have survived breast cancer.
Preventative surgery (prophylactic
mastectomy) may also prevent breast cancer. Bilateral prophylactic mastectomy
is the removal of both breasts in order to prevent breast cancer. Women with a
strong family history of BRCA1 or BRCA2 mutations may choose to have bilateral
prophylactic mastectomy in order to lower their risk of developing breast
cancer.
Breast Cancer Research
Doctors continue to search for more effective
and tolerable treatments for breast cancer. The funding for this research comes
from many sources, including advocacy groups throughout the country. Many of
the 2.5 million breast cancer survivors and their families choose to
participate in walk-a-thons and other fundraising events. This links each
individual fight against cancer into a common effort for progress.
Additional
Information on Breast Cancer
For more information about Breast Cancer,
please consider the following:
