What is it?

Overview

What Is It?
Breast cancer is a disease in which malignant (cancerous) cells are found in breast tissues.

Breast cancer is the most common cancer in women, other than skin cancer, and the second deadliest cancer in U.S. women; lung cancer is the deadliest. Approximately 182,460 cases of invasive breast cancer will be diagnosed in 2008, according to the American Cancer Society (ACS). Though an estimated 40,480 women will die from breast cancer, there are about 2.5 million breast cancer survivors in the U.S., according to the ACS.

Fortunately, the number of deaths caused by breast cancer has declined significantly in recent years, with the largest decreases in younger women—both Caucasian and African American. These decreases are probably the result of earlier detection and improved treatment.

The National Cancer Institute found a very significant drop in the rate of hormone-dependent breast cancers among women, the most common breast cancer, in 2003. In a study published in late 2006, researchers speculated that the drop was directly related to the fact that millions of women stopped taking hormone therapy in 2002 after the results of a major government study found the treatment slightly increased a woman's risk for breast cancer, heart disease and stroke. The researchers suggested that stopping the treatment prevented very tiny cancers from growing into tumors large enough to be identified by mammogram or touch because they didn't have the additional estrogen required to fuel their growth.

Breast cancer is a disease in which malignant (cancerous) cells are found in breast tissues. Each breast has 15 to 20 sections called lobes, which have many smaller sections called lobules. The lobes and lobules are connected by thin tubes called ducts. The different kinds of breast cancer that involve the lobes, lobules and/or ducts are:

• Ductal carcinoma in Situ (DCIS). Also known as intraductal carcinoma or non-invasive breast cancer, DCIS is confined to the ducts and has not invaded surrounding tissue. As the use of screening mammography has increased in the United States, the frequency of DCIS diagnosis has increased significantly. It is the most rapidly growing subgroup of breast cancer; one out of five cases of breast cancer is DCIS.
• Invasive ductal cancer. Also called infiltrating ductal carcinoma, this type of breast cancer is the most common of all breast cancers. It makes up about 80 percent of all newly diagnosed cases. It is found in the cells of the ducts and is usually a hard lump.
• Invasive lobular carcinoma. This form of breast cancer occurs at the ends of the ducts or in the lobules and accounts for 10 percent of invasive breast cancers.

Less common types of breast cancer:

• Mucinous carcinoma (colloid carcinoma). A rare type of invasive breast cancer, mucinous carcinoma is formed by mucin-producing cancer cells. Prognosis for this type of invasive breast cancer is generally better than for other more common types.
• Medullary carcinoma. This type of breast cancer accounts for five percent of all breast cancers and involves a distinct boundary between tumor tissue and normal tissue. It also differs from other forms of invasive ductal cancers in that it contains large cancer cells and immune system cells throughout the tumor. The prognosis for this type of cancer is generally better than for other invasive forms.
• Tubular carcinoma. Tubular carcinoma is characterized by tubular structures ringed with a single layer of cells. Only two percent of all breast cancers fall into this category. The prognosis is usually good.
• Invasive Paget's disease. A rare breast cancer in the ducts beneath the nipple accounting for only one percent of cases, invasive Paget's disease starts with an itchy, eczema-like rash around the nipple. Paget's disease can be associated with a noninvasive or invasive underlying mass. For noninvasive cases, it is believed that the cells have migrated from the ducts of the nipple to the nipple's epidermis, though this is still under study.
• Inflammatory carcinoma. This aggressive type of breast cancer accounts for one to three percent of all cases. Skin over the breast appears acutely inflamed and swollen because skin lymph vessels are blocked by cancer.

Diagnosis

Diagnosis

Your risk of developing invasive breast cancer at some time during your lifetime is one in eight. This sounds high, but if you consider the term, "lifetime," it helps put your risk in perspective. It means that one in 233 women in their 30s will be diagnosed with beast cancer; one in 69 in their40s; one in 36 in their 50s; and in 27 in their 60s. The "one in eight" applies to women in their 80s and 90s. However, as you can see, your risk for developing breast cancer increases with age. In fact, other than being a woman, age is the single greatest risk factor for breast cancer.

Yourrisk is higher if you have:

• A personal first-degree (mother, sister, daughter) family history

• Biopsy-confirmed atypical hyperplasia, or an overgrowth of abnormal cells that are not cancerous

• A mutation in the BRCA1 or BRCA2 tumor suppressor genes

• A mother, sister or daughter with a BRCA1 or BRCA2 mutation, even if you are yet to be tested yourself

• A lifetime risk of breast cancer that has been scored at 20 to 25 percent based on one of several accepted risk assessment tools that examine family history and other factors; see the American Cancer Society's Web site, www.cancer.org, for more information

• Had radiation to the chest between the ages of 10 and 30

• Li-Fraumeni syndrome, Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome or you have a first-degree relative with one of these syndromesLobular carcinoma in situ (LCIS), is not a true cancer, though it may be a marker for later cancer risk. Most experts agree that LCIS does not often become an invasive cancer, but women with LCIS do have an increased risk of developing invasive breast cancer.

• A biopsy-confirmed atypical lobular neoplasia (ALN), which is a noncancerous breast disease characterized by the growth of abnormal cells. ALN may be discovered on the mammogram or when a biopsy is done for a lump.

Your risk is somewhat higher if you have:

• Dense breast tissue

• Early menstruation (beginning at 12 or younger)

• Late menopause (age 55 or older)

• Never had children or had your first baby after age 30

• Have used hormone therapy for a long time

Your risk may be higher if you:

• Smoke

• Drink heavily

• Are obese

• Are a gay or bisexual woman. These women have a greater risk of breast cancer than other women not because of their sexual orientation, but because they are less likely to have had children. They also may have more lifestyle-related risk factors for breast cancer than heterosexual women, including obesity and cigarette smoking. If you are a lesbian or bisexual woman, you may want to find a lesbian- and/or bisexual-sensitive health professional and schedule regular physicals that include clinical breast examinations and mammography.

You may have read or heard that an induced abortion or miscarriage can increase a woman's risk of developing breast cancer later in life. But according to the National Cancer Institute (NCI), newer studies have consistently shown no association between miscarriages or induced abortions and breast cancer risk.

A majority of women will have one or more risk factors for breast cancer. However, most risks are so low that they only partly explain the high frequency of the disease in the population.

While you can't alter some of your personal risk factors for developing breast cancer, such as age or family history, you can adopt specific lifestyle choices, such as maintaining your ideal body weight and exercising, to reduce your risk of the disease.

Early detection of breast cancer, however, provides the best opportunity for successful treatment and reduces your chances of dying from breast cancer.

There are three main ways to detect abnormalities in your breasts that may be cancerous: breast self-examination, mammograms and regular breast exams by your health care professional. Other imaging studies such as ultrasound and MRI (magnetic resonance imaging) can also help find cancer in the breast. As a result of new guidelines released by the ACS in March 2007, MRI together with a yearly mammogram is now recommended for women with the highest risk of developing breast cancer (see the list above for risks that are considered to be higher than average). MRI scans are more sensitive than mammograms at detecting an abnormality in women with dense breasts. The two tests together give health care professionals a better chance of finding breast cancer in its early stages, when it is the most treatable. The new guidelines recommend that high-risk women begin getting MRIs and mammograms at age 30, unless their health care professionals suggest a different age.

Breast self-exam (BSE) is an option for women age 20 and older. Research has shown that BSE slightly increases a woman's chance of finding a breast lump compared to discovering one by chance. Overall, the main goal of a BSE is to help a woman become familiar with the look and feel of her breasts so she can report any changes to her health care provider right away. Some women feel very comfortable taking a step-by-step approach to doing a monthly BSE. Other women prefer to examine their breasts in a less systematic way, while they are showering or getting dressed, with an occasional more thorough exam. As long as a woman monitors the look and feel of her breasts regularly, either technique is acceptable.

Health care professionals should discuss the benefits and limitations of BSE with women 20 and older so they can make informed decisions about the practice.

Ask your health care professional to show you how to perform a BSE correctly. You may also want to ask for a brochure to help when you get home. It may take several months for you to become familiar with the routine and to learn what to expect to feel. But with practice, BSE can increase your chances of noticing anything abnormal about your breasts.

As you perform BSE, remember the seven "Ps:"

• Position to assume while inspecting or palpating (feeling) the breasts

• Perimeter (boundaries) of breast tissue to be examined

• Palpation using the pads of three fingers

• Pressure of the fingers

• Pattern of search

• Practice of feedback

• Plan of action for breast health

If you find a suspicious lump or notice something else abnormal, make an appointment with your health care professional. He or she will perform an exam and will likely have you undergo a mammogram. The majority of breast changes found by women who regularly perform BSEs are not cancerous.

Mammograms

The value of mammography is that it can identify potentially cancerous breast abnormalities at an early stage before they can be felt. While mammograms can detect a breast lump up to two years before it can be felt during a physical examination, they can miss up to 20 percent of breast cancers.

According to the ACS March 2007 updated screening guidelines, women at a high risk of breast cancer age 30 and older (or at an age determined by their health care professionals) should have:

• An annual mammogram together with an MRI

According to the ACS breast cancer screening guidelines, women at average risk of breast cancer age 40 and older should have:

• An annual mammogram

• An annual clinical breast exam performed by a health care professional

While BSEs are optional, as noted above, they are still strongly encouraged.

According to ACS, women ages 20 to 39 should have:

• A clinical breast exam performed by a health care professional at least every three years, as part of their periodic (regular) health exam

A mammogram is a specialized x-ray of your breasts from various angles. Although it doesn't hurt, it can be uncomfortable for some women or even a little embarrassing. A health care professional moves and flattens (breast compression) your breasts on the x-ray machine so it is in the best position for taking x-ray images. The entire procedure typically takes less than 15 minutes.

Ultrasound and MRI

If something abnormal is detected in a mammogram, the next step is usually to take additional x-ray views or an ultrasound.

Ultrasound is also used to create visual images of breast tissue. Ultrasonography, or ultrasound, uses high-frequency sound waves. The images it creates can be viewed on a monitor and allows your health care professional to see if a breast lump is a fluid-filled cyst (not cancer) or a solid mass (which may or may not be cancer). Ultrasound may be used with a mammogram, and the images produced are printed and/or stored as video.

Use of MRI of the breast is now recommended together with an annual mammogram as a standard diagnostic tool in women at a high risk of breast cancer. This technology uses magnetic fields to show differences between normal and abnormal tissue.

For an MRI scan, you lie in a specially designed structure that houses the magnetic field. Contrast material is injected into your veins, and the MRI image shows the dye coursing through the blood vessels in your breasts.

This test is used to detect cancer, determine the extent of disease, monitor response to therapy and screen women at high risk for breast cancer.

A relatively new technology called CADstream, designed specifically for breast MRI, makes interpretation of MRI data more efficient, as well as improves the images produced by the scan. CADstream uses a computer-aided detection (CAD) system that helps radiologists increase quality control of breast MRI studies (it corrects for patient movement during a scan) and eliminates manual processing of hundreds of images usually produced by one scan.

Computer-assisted diagnosis, or CAD, is also used during a second reading of mammograms to improve the accuracy of the reading.

Biopsy

Even after an ultrasound or mammogram, if your health care professional still believes the area is suspicious, he or she may recommend a core-needle biopsy, taking a sample of breast tissue by needle and sending it to a pathologist to determine if it's cancer. Biopsies can usually be done in your doctor's office under local anesthesia. Fine needle aspiration is frequently performed. However, the rate of false negatives is very high and most often additional studies, like checking for estrogen or progesterone receptors based on an aspiration, are hard to perform.

If Breast Cancer is Found

If breast cancer is found, more tests will be done to find out the size and extent of the cancer in the breast and to determine whether the cancer has spread from the breast to other parts of the body. This is called staging. To plan treatment, your health care professional needs to know the stage of the disease. The following stages are used for breast cancer:

• Stage 0: Carcinoma in situ: About 20 percent of breast cancers are very early cancers, sometimes called ductal carcinoma in situ (DCIS).

• Stage I: The cancer is no larger than two centimeters (about one inch) and cannot be detected outside the breast.

• Stage II: Any of the following may be true:

  • The cancer is no larger than two centimeters but has spread to the lymph nodes under the arm (the axillary lymph nodes).

  • The cancer is between two and five centimeters.

  • The cancer may or may not have spread to the lymph nodes under the arm (axillary lymph nodes).

• Stage III: Stage III is divided into stages IIIA and IIIB. Stage IIIA is defined by either of the following: The cancer is smaller than five centimeters and has spread to the lymph nodes under the arm, and the lymph nodes are attached to each other or to other structures; or, the cancer is larger than five centimeters and may or may not have spread to the lymph nodes under the arm.

  Stage IIIB is defined by either of the following: The cancer has spread to tissues near the breast (skin or chest wall, including the ribs and the muscles in the chest); or, the cancer has spread to lymph nodes inside the chest wall along the breastbone.

• Inflammatory breast cancer: This class of breast cancer is uncommon. The breast looks as if it's inflamed because it is red, swollen and warm. The skin may show signs of ridges or it may have a pitted appearance. Also, a biopsy of skin will show tumor cells. This type of breast cancer tends to be more aggressive. Inflammatory breast cancer that is not detected outside of the breast and underarm lymph nodes is Stage IIIB.

• Stage IV: The cancer has spread to other organs of the body, most often the bones, soft tissue (skin), lungs, liver or brain.

• Recurrent: Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the breast, in the soft tissues of the chest (the chest wall) or in another part of the body.

Treatment

Treatment

The treatment you and your health care professional choose will depend upon many things. Treatment often includes surgical, radiation and medical therapy.

The most common surgical treatment for invasive cancer is lumpectomy with sentinel lymph node biopsy technique. (Described below.) Dissection of axillary lymph node (a large group of lymph nodes located in various places) and modified radical mastectomy, are other common surgical treatments for invasive cancer.

• Lumpectomy, also known as excisional biopsy or wide excision, is a breast-conserving surgical procedure. Ithas become more common in the last 10 years as a means of treating early-stage cancer. In fact, results from two major studies that appeared in the October 2002 New England Journal of Medicine confirmed earlier studies that lumpectomy followed by radiation to the breast is just as effective as mastectomy in treating breast cancer.

• During lumpectomy, a surgeon removes just the tumor along with a margin of healthy tissue, leaving the remainder of the breast intact, followed by radiation. Regardless of whether you choose lumpectomy or mastectomy, an axillary lymph node dissectionshould be performed for invasive forms of the disease.

• Simple or total mastectomy: The entire breast is removed.

• Modified radical mastectomy: One of the most common breast cancer surgeries performed (the other is lumpectomy with axillary lymph node dissection). The entire breast is removed along with underarm lymph nodes (sometimes the lining over the chest muscles and, more rarely, part of the chest wall muscle is also removed).

Adjuvant Therapy

In addition to surgery, adjuvant therapy is used to kill any cancer cells that may have spread. In deciding whether adjuvant treatment is necessary, your doctor takes into account the extent (stage) and nature of your disease, general health and other prognostic factors.

The choice of the type of adjuvant therapy depends on many factors, such as whether the cancer cells contain hormone receptors (estrogen and progesterone), Her2/neu expression, the grade of tumor and the size of tumor and lymph nodes. Most women receive some form of adjuvant therapy.

Adjuvant therapy usually begins between two and 12 weeks after surgery. It includes chemotherapy and/or hormone therapy, as well as radiation therapy.

• Chemotherapy involves a combination of anticancer drugs. These drugs are powerful and can have many side effects. Anticancer drugs are given by mouth or by injection into a blood vessel. Either way, the drugs enter the bloodstream and travel throughout the body.

  Chemotherapy is given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. Most patients receive treatment in an outpatient part of the hospital or at the doctor's office. Adjuvant chemotherapy usually lasts for three to six months.

  Hormone therapy deprives cancer cells of the female hormone estrogen, which some breast cancer cells need to grow. For many women, hormone therapy means treatment with the drug tamoxifen or an aromatase inhibitor, such as anastrozole (Arimidex), letrozole (Femara) or exemestane (Aromasin).

  Some premenopausal patients may have surgery to remove their ovaries, which are a woman's main source of estrogen. Or they may be treated with a medication to reduce ovarian function.

  Like anticancer drugs, tamoxifen and the aromatase inhibitors are taken once a day via pill and are absorbed into the bloodstream. Most women take hormone therapy for five years. In 2003, the results of a clinical trial examining whether the aromatase inhibitor letrozole prevents late recurrences of breast cancer were reported in the New England Journal of Medicine. The data showed that taking the drug after a five-year course of tamoxifen significantly reduced the incidence of recurrent breast cancer in postmenopausal women. In fact, the study was stopped prematurely to give those women who were taking a placebo the opportunity to receive the drug.

  Another study, this one reported in a 2004 issue of the New England Journal of Medicine, found that taking exemestane following two to three years of tamoxifen improved cancer-free survival as compared with the standard five-year tamoxifen treatment in estrogen receptor-positive breast cancers.

  A study published in the Lancet in late 2004, reported on the results of a clinical trial comparing the use of aromatase inhibitors to tamoxifen over five years. The trial, called the Arimidex, Tamoxifen, Alone or in Combination (ATAC) Trial, found that anastrozole significantly reduced breast cancer recurrences compared to tamoxifen, in both breasts as well as in other parts of the body. Women taking anastrozole also experienced fewer side effects than those taking tamoxifen, especially hot flashes, blood clots, vaginal discharge/bleeding and stroke, but were more likely to experience a bone fracture or other musculoskeletal disorder.

  Tamoxifen also carries some risks, however, which prompted the FDA to issue a "black box" warning for the drug's label. The warning notes that an increased risk of stroke, pulmonary emboli and fatal uterine cancers may accompany use of the drug, and suggests patients discuss these risks with their health care professionals.

• Radiation therapy is used in patients having a lumpectomy. It is also sometimes used after a mastectomy for women with large cancer tumors or with four or more positive lymph nodes, or when the margins of the surgical removal show some cancer cells. Such treatment can help destroy breast cancer cells that may have been left behind in the area where the breast was.

Choosing the Right Treatment

So how do you know which treatment to choose? Your health care professional will try to determine your prognosis—the likely outcome after treatment. One indicator most commonly used is lymph node involvement.

Cancer cells commonly spread from the breast to lymph nodes in underarm and chest areas. To determine if and how far breast cancer has spread, and which treatment option may be the best option, a number of lymph nodes are typically removed for biopsy to see if they contain cancer cells.

If cancer is found, the woman is said to be "node positive." If the lymph nodes are free of cancer, the patient is said to be "node negative." Women who have multiple positive nodes are more likely than those with negative nodes to have a systemic recurrence. Plus, the more lymph nodes that are involved, the more serious the cancer.

A procedure that is widely used is called sentinel lymph node biopsy. It is effective as a less invasive technique than conventional axillary lymph node dissection to determine if certain cancers have spread.

Sentinel nodes are a small cluster of lymph nodes to which cancer first spreads from the primary tumor. In a sentinel node biopsy, a surgeon removes only one or a few of the sentinel nodes instead of the larger number of nodes typically removed for biopsy. The surgeon identifies the sentinel nodes to remove by injecting a radioactive tracer substance or dye near the tumor. Then, using a scanner, he or she searches for the nodes containing the dye/tracer and removes them to check for cancer cells.

A study reported in a 2003 issue of the New England Journal of Medicine found that sentinel node biopsies of women with small breast cancers caused fewer side effects (such as swelling, pain and numbness) than conventional biopsy procedures and was a safe and accurate way to evaluate lymph nodes in women with small breast cancers.

• Tumor size. In general, patients with small tumors have a better prognosis than do patients with large tumors.

• Histologic grade. This term refers to how much the tumor cells resemble normal cells when viewed under the microscope. The grading scale usually ranges from 1 to 3. Grade 1 tumors are composed of cells that closely resemble normal ones. Grade 3 tumors contain very abnormal-looking and rapidly growing cancer cells.

• Hormone receptors. Cells in the breast contain receptors for the female hormones estrogen and progesterone. These receptors allow the breast tissue to grow or change in response to changing hormone levels. Research finds that about two-thirds of all breast cancers contain significant levels of estrogen receptors. These tumors are said to be estrogen receptor positive (ER+). About two-thirds of ER+ tumors also test positive for receptors to progesterone (PR+). Tumors that are hormone receptor positive are more likely to respond to hormone therapy. These tumors also tend to grow less aggressively, resulting in a better prognosis for patients with ER+ tumors.

• Proliferative capacity of a tumor. This characteristic refers to the rate at which cancer cells in a tumor divide to form more cells. Cancer cells that have a high proliferative capacity divide more often and can be more aggressive (fast growing) than those in tumors with a low proliferative capacity.

• Oncogene expression and amplification. An oncogene is a gene that causes or promotes unrestrained growth of a cell. The activation of an oncogene can convert a normal cell into a tumor cell. Research finds that women whose tumor cells contain certain oncogenes may be more likely to have a recurrence. Tests for oncogenes are available at most medical facilities. One such test looks for the presence of the protein HER2.

About 25 to 30 percent of women with breast cancer have an excess of a protein called HER2, which makes tumors grow quickly. Two genetically engineered drugs, trastuzumab (Herceptin) and lapatinib (Tykerb), bind to HER2 to help fight cancer cells. Trastuzumab is an intravenous treatment that is used alone or in combination with chemotherapy drugs. Most recently, in 2005 two studies published in the New England Journal of Medicine found that taking Herceptin for one year after surgery reduces the risk of breast cancer recurrence by half. This was an unprecedented improvement in treating this disease and will impact the way all oncologists practice.

Tykerb, approved in March 2007, is used in combination with capectabine (Xeloda), another cancer drug, in patients with advanced HER2 positive tumors. The combination of Tykerb and Xeloda is to be used in women who have received prior therapy with other cancer drugs, including Herceptin. Tykerb, a new molecular entity (NME), is a kinase inhibitor that works by depriving tumor cells of signals that they need to grow.

Pregnancy and Breast Cancer

As many as four percent of breast cancers occur during pregnancy or within the first year after giving birth. Changes in the breast during pregnancy and lactation may make detection difficult. Pregnancy also limits the treatment options for breast cancer.

Surgery remains an option, however, with special care taken during anesthesia, but radiation must be delayed until after the pregnancy because of its dangerous effects on the developing fetus.

However, chemotherapy can be given in the second or third trimester. Or, for women who want to save their breasts, chemotherapy can be given before surgery and radiation delayed until after delivery.

Post-Mastectomy and Reconstruction

After a mastectomy, some women may choose to wear a prosthesis (an artificial breast form). Others may decide to have breast reconstruction.

There are several methods to rebuild the breast after mastectomy. The method must be tailored to the individual patient's needs. The simplest operation is to place an implant behind the remaining muscle and create a mound that resembles a normal breast. In some cases, breast reconstruction may be performed immediately following a mastectomy.

If you had a great deal of tissue removed, more skin can be created with a tissue expander. This is a balloon-type device that is placed beneath the muscle and skin. Over several weeks this is made larger by almost painless injections of saline in the health care provider's office. After several months, the expander is replaced by a permanent implant.

Another approach is flap surgery. It uses tissue from your back, thigh or abdomen to rebuild the breast. This tissue is moved into its new position, leaving a defect at the donor site. It is more major surgery. If you had radiation, which can cause significant scarring, a flap may be the best option.

The scar from breast reconstruction depends on the method used. With the flap, for example, you will have a scar at the site where the flap is removed (the donor site) and another around the flap on the breast.

You can read more on breast reconstruction on Healthywomen.org.

Whichever method is used, additional surgery is needed if you want to have the nipple and areola rebuilt.

Regardless of whether you have a mastectomy alone or the added reconstructive surgery, there is a period of time after the surgeries when you can expect a certain amount of pain and limited movement. Recovery times vary depending on your surgery and overall health. Various programs are available to help you regain function; ask your health care professional for a referral to one of those programs.

Prevention

Prevention

There is no known way to prevent breast cancer. But there are some things you can do to reduce your risk of breast cancer.

Approved in 1998, the drug tamoxifen has been shown to slash the risk of breast cancer in high-risk women by up to 50 percent. Also, preliminary results of a 2006 study on postmenopausal women found that the osteoporosis drug raloxifene was as effective as tamoxifen at lowering breast cancer risk, with slightly fewer side effects. The study, called STAR (Study of Tamoxifen and Raloxifene)—one of the largest breast cancer prevention studies ever—compared both drugs, with raloxifene pulling just slightly ahead of tamoxifen. If you have a high risk for breast cancer, talk to your health care professional about tamoxifen, raloxifene or other similar drugs to prevent breast cancer.

Although prevention is difficult, you have a much better prognosis if you can find and treat breast cancer early. To do that, follow this advice:

• At age 40 for women at an average risk of breast cancer, begin having screening mammograms every year.

• For women at high risk of breast cancer, starting at age 30 or an age determined by your health care professional, begin having annual screening mammograms together with magnetic resonance imaging (MRI).

• To make sure you get the best possible mammogram, look for the FDA certificate, which should be prominently displayed at the facility. Facilities not meeting FDA requirements may not lawfully perform mammography.

• If you're in your 20s and 30s and at an average risk, have your health care professional examine your breasts at least once every three years and annually thereafter.

• Become familiar with how your breasts feel and what is "normal" for you; examine your breasts periodically and see a health care professional if you feel or see any changes that don't go away after one menstrual cycle.

• Eat a healthy diet rich in fruits and vegetables, maintain your ideal body weight, exercise regularly, and drink in moderation, if at all. A University of Washington (Seattle) study found that exercise and lack of obesity in adolescence significantly delayed the onset of breast cancer, including onset in high-risk women who carried genetic mutations for the disease.

• Engage in frequent and regular physical exercise. Some studies suggest it may reduce your breast cancer risk.

• If you're at very high risk for breast cancer because of a strong family history of breast and ovarian cancer, an inherited breast cancer gene abnormality or previous breast cancer, talk to your health care professional about a prophylactic mastectomy.

Prophylactic mastectomy is an aggressive preventive surgery that removes both breasts before any cancer is detected. It can reduce the risk of breast cancer by approximately 90 percent, but doesn't eliminate the risk entirely. Removing the ovaries (prophylactic oophorectomy) may also be a preventive choice for women with an inherited breast cancer gene abnormality, since the risk for ovarian cancer is also greater for these women.

Visit www.breastcancer.org for more information.

Facts to Know

Facts to Know

1. An estimated 182,460 new cases of invasive breast cancer will be diagnosed in 2008. Approximately 40,480 women will die from breast cancer in 2008. Breast cancer is the most common site of cancer in women (besides skin cancer) and the second-leading cause of cancer death in women.

2. The five-year relative survival rate for localized breast cancer has increased from 72 percent in the 1940s to close to 100 percent for stage 0 and I breast cancers, and 92 percent for stage IIA. If the cancer is in stage IIB, the five-year survival rate is currently 81 percent, and it is 67 percent for stage IIIA, 54 percent for stage IIIB, and 20 percent for stage IV.

3. Survival after a diagnosis of breast cancer continues to decline beyond five years. Ten-year survival and beyond is also stage-dependent, with the best survival observed in women with early stage disease.

4. Well-known estrogen-related risks for developing breast cancer include early menstruation (at age 12 or younger); late menopause (after age 55); and no full-term pregnancy or first child until after age 30.

5. Approximately 80 percent of biopsied breast abnormalities are noncancerous, but any breast lump must be evaluated by a physician. New, less invasive biopsy procedures permit removal of breast tissue in a physician or radiologist's office.

6. Sometimes more than one mammogram may be necessary to evaluate an abnormality. Common reasons for additional mammograms include film views that are unclear or different views requested by the radiologist.

7. Some mammography centers are able to provide immediate interpretation of your mammogram. This service can help prevent anxiety caused by waiting days to hear your results. Any additional films required also can be taken during the same visit.

8. Many women panic when they see the "one in eight women will be diagnosed with breast cancer in her lifetime" statistic, but when the numbers are broken down, this means one in 233 women in her thirties will be diagnosed with breast cancer; one in 69 in her forties; one in 36 in her fifties; and one in 27 in her sixties. The annual risk of a 85-year-old woman being diagnosed with breast cancer is 15 times that of a 30-year-old woman.

9. Some breast cancer cases are the result of a mutation in the BRCA 1 or 2 genes, which can be inherited from a family member. Hereditary breast cancer makes up approximately five to 10 percent of all breast cancer. Some altered genes related to breast cancer are more common in certain ethnic groups. Women who have an altered gene related to breast cancer and who have had breast cancer in one breast have an increased risk of developing breast cancer in the other breast. These women also have an increased risk of developing ovarian cancer and may have an increased risk of developing other cancers.

10. Different types of treatment are available for patients with breast cancer. Some treatments are standard, and some are being tested in clinical trials. The four types of standard treatment currently used are surgery, radiation therapy, chemotherapy and hormone therapy.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about breast cancer so you're prepared to discuss this important health issue with your health care professional.

1. What is my risk for developing breast cancer?

2. My mother had breast cancer. Will I develop it, too?

3. What can I do to reduce my risks for developing breast cancer?

4. What are the symptoms of breast cancer?

5. How is breast cancer diagnosed?

6. Are breast self-exams really worth doing? Will you show me how to do one?

7. How often and when should I do a breast self-exam?

8. What is a clinical breast exam? How often do I need to have one?

9. What is a screening mammogram? Should I have one? Does it hurt?

10. Are low-cost or free mammograms available? I'm not sure I can afford one.

11. Can breast cancer be treated? What treatments are available?

12. I've been taking birth control pills for years. Do they increase my risk for developing breast cancer?

13. Does postmenopausal hormone therapy cause breast cancer?

Key Q&A

Key Q&A

1. Why is it important to find a lump or other breast abnormality early?

   If detected early, breast cancer can often be treated effectively with surgery that preserves the breast, followed by radiation therapy. This local therapy is often accompanied by systemic chemotherapyand/or hormonal therapy. Five-year survival after treatment for —stage 0 and stage 1 breast cancers is close to 100 percent.

2. I'm only 25—do I need to worry about breast cancer?

   Although it is rare, breast cancer can occur in women under 30. Make an effort to find out if breast cancer has occurred in any of your relatives. If so, speak to your health care professional about a plan of action. A typical plan includes periodic breast self-examinations, an examination by a health care professional at least every three years, and regular mammograms and MRIs beginning at age 30. Breast cancer incidence increases with age, rising sharply after age 40. About 80 percent of invasive breast cancer occurs in women over age 50.

3. A friend told me her routine mammogram was "abnormal." What does this mean, and what should a woman do if she receives this type of report?

   Along with the increased use of mammography comes a greater chance that a woman will have a result that needs more study. Any mammogram with an abnormal report is cause for additional testing to determine the nature of the abnormality. It may not necessarily be cancer, but only more testing will tell you this for sure. Additional testing can involve more mammograms and possibly a biopsy of the abnormality.

4. My doctor said my mammogram was suspicious—what does that mean?

   Mammograms that are labeled "suspicious" or "abnormal" means there are signs that are strongly suggestive of a cancer, such as an irregular mass, contraction of the tissue around it, groups of small calcifications, underarm lymph node involvement or thickening of the skin.

5. What could it be if it is not breast cancer?

   A frequent type of abnormality appears as calcifications, which are seen as white specks grouped in clusters or in strings on the films from your mammogram. Calcifications themselves are not cancer but may be present in the midst of a cancer. Clustered small calcifications alone are associated with about a 25 percent risk of cancer. The way these calcifications are positioned within the breast and their number and shape can provide a radiologist with a suggestion of whether these should be left alone or further examined for invasive or preinvasive disease. If your mammogram reveals a mass, one that is star-shaped or irregularly bordered is more suspicious than a round or smooth-edged mass, which is more likely to be a fluid-filled cyst.

6. My doctor ordered a second mammogram, and it's still not clear. What next?

   After re-imaging or a follow-up mammogram, if unresolved concerns persist, the next step is to learn more about the area in question. If a cyst is suspected, a sonogram (ultrasound) can often determine if a mass is a cyst that can be drained or is solid and requires a biopsy. Many biopsy options exist today, including image-guided core needle procedures that remove small quantities of tissue from the area in question and can be completed in a doctor's office.

7. How do I know if I'm at high risk of getting breast cancer?

   A woman is considered at higher risk for breast cancer if she has a mother, sister or daughter who has been diagnosed with breast cancer. About five to 10 percent of all breast cancer patients are believed to carry a mutation in the BRCA1 or BRCA2 gene. A carrier of BRCA1/2 may have as high as an 80 percent lifetime chance of developing breast cancer and a 60 percent risk of developing ovarian cancer.

8. I have atypical hyperplasia. What does that mean?

   This type of noncancerous breast disease is characterized by a growth of abnormal cells within the breast ducts. Premenopausal women with a biopsy-confirmed diagnosis of atypical hyperplasia are at increased risk for later developing invasive breast cancer.

9. I have large breasts and I've been having a strange pain in one of them. Am I at risk of having breast cancer?

   There is no known correlation between breast size and cancer. Also, breast pain is very commonly due to noncancerous conditions and is not usually the first symptom of breast cancer. However, you should contact your health care professional about any unusual symptoms that persist.

10. I want to have breast reconstruction, but what about the horror stories about silicone implants?

    There are various alternatives, including saline implants or using tissue from your abdomen or from other areas of the body to reconstruct a breast. Depending on your situation, you may even be able to have breast reconstruction at the time of mastectomy. But you would likely have to return to surgery if you wanted a nipple and areola added. Nowadays, however, you can have breast reconstruction as an outpatient, depending on your health and stage of cancer.

Lifestyle Tips

Lifestyle Tips

1. Coping with a breast cancer diagnosis

Don't ever blame yourself for getting breast cancer. Scientists have identified a number of risk factors, but no one knows what causes this disease. Racking your brain for reasons is a waste of energy; there are no answers. And don't feelpressured to carry out your "to-do" list to the degree that you did before your diagnosis. For example, forgive yourself if you are late for a lunch date or forget to send your nephew a birthday card. People will understand.

2. Fatigue to be expected

If you are undergoing cancer treatment or expect to be, it's important to plan for the eventuality that you may feel very fatigued during the treatment period. If possible, arrange in advance to have friends and family pitch in with meal preparation, child care, caring for your pets and other household tasks in case you just don't feel up to doing such things. Speak with your employer about taking time off or working flexible hours while you're undergoing treatments. Studies have shown that general fatigue, including fatigue caused by anemia, affects more than three-quarters of patients undergoing cancer treatment. Other side effects of treatment can include nausea, depression and pain.

3. HT increases breast cancer risk

Taking combined estrogen-progestin hormone therapy may increase your breast cancer risk more than taking estrogen alone, according to a study of 16,000 women in the federally funded Women's Health Initiative (WHI). The most recent results from the study found that not only did combined hormone therapy increase the risk of breast cancer, it also increased the chance that the cancer would be found at a later stage.

4. Free and low-cost mammograms available

Most health insurers and Medicare cover mammography, an x-ray screening for breast cancer that generally costs $50 to $150. If you are not insured and cannot afford mammography, call the American Cancer Society, 1-800-ACS-2345, your state health department or the nearest YWCA (ask about the ENCOREplus program) for referrals to free or low-cost mammography to qualifying women.

You can also e-mail the National Breast Cancer Foundation at info@nationalbreastcancer.org or call the U.S. Centers for Disease Control and Prevention (CDC) at 1-800-311-3435. October is National Breast Cancer Awareness Month, when many mammography facilities offer reduced fees and extended hours. If you are unable to schedule a mammogram another time of year, it helps to call in September to reserve an appointment.

5. Lumpectomy 'standard of care' for breast cancer patients

In the past, it was assumed that breast cancer patients who are 65 or older who underwent lumpectomy followed by radiation did not fare as well as their younger counterparts who had the same breast-conservation therapy (BCT). However, more recent studies find that BCT provides excellent disease-free survival rates among elderly women with breast cancer. In an 2001 study, the five- and 10-year survival rates were 96 percent and 91 percent, respectively. Experts recommend that elderly patients who do not suffer from severe coexisting diseases have this procedure.

Organizations and Support

Organizations and Support

For information and support on coping with Breast Cancer, please see the recommended organizations, books and Spanish-language resources listed below.

Organizations

African American Breast Cancer Alliance
Website: http://www.aabcainc.org
Address: P.O. Box 8981
Minneapolis, MN 55408
Phone: 612-825-3675
Email: aabca@aabcainc.org

American Cancer Society (ACS)
Website: http://www.cancer.org
Address: 250 Williams Street
Atlanta, GA 30303
Hotline: 1-800-ACS-2345 (1-800-227-2345)
Phone: 404-315-1123

Breast Cancer Action
Website: http://www.bcaction.org
Address: 55 New Montgomery St, Suite 323
San Francisco, CA 94105
Hotline: 1-877-2STOPBC (1-877-278-6722)
Phone: 415-243-9301
Email: info@bcaction.org

Breast Cancer Connections
Website: http://www.bcconnections.org/
Address: 390 Cambridge Avenue
Palo Alto, CA 94306
Phone: 650-326-6686
Email: info@bcconnections.org

Breast Cancer Network of Strength
Website: http://www.networkofstrength.org
Address: 212 West Van Buren St., Suite 1000
Chicago, IL 60607
Hotline: 1-800-221-2141 (English) 1-800-986-9505 (Español)
Phone: 312-986-8338

Breastcancer.org
Website: http://www.breastcancer.org
Address: 7 East Lancaster Avenue, 3rd Floor
Ardmore, PA 19003
Email: comments@breastcancer.org

Breast Cancer Research Foundation
Website: http://www.bcrfcure.org
Address: 60 East 56th Street, 8th Floor
New York, NY 10022
Hotline: 1-866-FIND-A-CURE (346-3228)
Phone: 646-497-2600
Email: bcrf@bcrfcure.org

Cancer Care, Inc.
Website: http://www.cancercare.org
Address: 275 Seventh Ave., Floor 22
New York, NY 10001
Hotline: 1-800-813-HOPE (1-800-813-4673)
Phone: 212-712-8400
Email: info@cancercare.org

Cancer Information and Counseling Line (CICL)
Address: AMC Cancer Research Center
1600 Pierce Street
Denver, CO 80214
Hotline: 1-800-525-3777
Email: contactus@amc.org

Cancer Support Community
Website: http://www.gildasclub.org/
Address: Gilda's Club Worldwide
48 Wall Street, 11th Floor
New York, NY 10005
Phone: 888-GILDA-4-U
Email: info@gildasclub.org

FDA Breast Implant Information Hotline
Website: http://www.fda.gov/cdrh/breastimplants
Address: U.S. Food and Drug Administration
5600 Fishers Lane
Rockville, MD 20857
Hotline: 1-888-INFO-FDA (1-888-463-6332)

FDA Certified Mammography Facilities
Website: http://www.fda.gov/CDRH/MAMMOGRAPHY/certified.html
Address: U.S. Food and Drug Administration
5600 Fishers Lane
Rockville, MD 20857-0001
Hotline: 1-800-838-7715

FORCE: Facing Our Risk of Cancer Empowered
Website: http://www.facingourrisk.org
Address: 16057 Tampa Palms Blvd. W, PMB #373
Tampa, FL 33647
Hotline: (866)288-RISK
Phone: (954) 255-8732
Email: info@facingourrisk.org

Living Beyond Breast Cancer (LBBC)
Website: http://www.lbbc.org
Address: 354 West Lancaster Ave., Suite 224
Haverford, PA 19041
Phone: 888-753-5222
Email: mail@lbbc.org

Mothers Supporting Daughters with Breast Cancer
Website: http://www.mothersdaughters.org
Address: 25235 Fox Chase Drive
Chestertown, MD 21620
Phone: 410-778-1982
Email: msdbc@verizon.net

National Breast and Cervical Cancer Early Detection Program
Website: http://www.cdc.gov/cancer/nbccedp
Address: CDC/DCPC
4770 Buford Hwy, NE MS K-64
Atlanta, GA 30341
Hotline: 1-800-CDC-INFO (1-800-232-4636)
Email: cdcinfo@cdc.gov

National Breast Cancer Coalition (NBCC)
Website: http://www.natlbcc.org
Address: 1101 17th Street, NW, Suite 1300
Washington, DC 20036
Hotline: 1-800-622-2838
Phone: 202-296-7477

National Cancer Institute (NCI)
Website: http://www.nci.nih.gov
Address: NCI Public Inquiries Office
6116 Executive Boulevard, Room 3036A
Bethesda, MD 20892
Hotline: 1-800-4-CANCER (1-800-422-6237)
Phone: TTY: 1-800-332-8615

National Coalition for Cancer Survivorship (NCCS)
Website: http://www.canceradvocacy.org
Address: 1010 Wayne Ave., Suite 770
Silver Spring, MD 20910
Hotline: 1-877-NCCS-YES (1-877-622-7937)
Phone: 301-650-9127
Email: info@canceradvocacy.org

Prevent Cancer Foundation
Website: http://www.preventcancer.org
Address: 1600 Duke Street, Suite 500
Alexandria, VA 22314
Hotline: 1-800-227-2732
Phone: 703-836-4412

SHARE - Self-Help for Women with Breast or Ovarian Cancer
Website: http://www.sharecancersupport.org
Address: 1501 Broadway, Suite 704A
New York, NY 10036
Hotline: 1-866-891-2392
Phone: 212-719-0364

Sharsheret
Website: http://www.sharsheret.org
Address: 1086 Teaneck Road, Suite 3A
Teaneck, NJ 07666
Hotline: 1-866-474-2774
Email: info@sharsheret.org

Sister's Network Inc.
Website: http://www.sistersnetworkinc.org
Address: 2922 Rosedale St
Houston, TX 77004
Hotline: 1-866-781-1808
Phone: 713-781-0255
Email: infonet@sistersnetworkinc.org

Support Connection - Breast and Ovarian Cancer Support
Website: http://www.supportconnection.org
Address: 360 Underhill Ave., 2nd Floor
Yorktown, NY 10598
Hotline: 1-800-532-4290
Phone: 914-962-6402
Email: info@supportconnection.org

Susan G. Komen for the Cure
Website: http://www.komen.org
Address: 5005 LBJ Freeway, Suite 250
Dallas, TX 75244
Hotline: 1-877-GO-KOMEN (1-877-465-6636)

Women's Cancer Resource Center
Website: http://www.wcrc.org
Address: 5741 Telegraph Avenue
Oakland, CA 94609
Hotline: 1-888-421-7900
Phone: 510-420-7900
Email: info@wcrc.org

Young Survival Coalition
Website: http://www.youngsurvival.org
Address: 61 Broadway, Suite 2235
New York, NY 10006
Hotline: 1-877-YSC-1011 (1-877-972-1011)
Phone: 646-257-3000
Email: info@youngsurvival.org

Books

A Gynecologist's Second Opinion: The Questions and Answers You Need to Take Charge of Your Health
by William H. Parker, Rachel L. Parker

Breast Cancer: Myths & Facts: What You Need to Know
by S. Eva Singletary

Breast Cancer: The Notebook
by Julia Chiappetta

Coming Out of Cancer: Writings from the Lesbian Cancer Epidemic
by Victoria A. Brownworth

Complete Book of Breast Care
by Niels H. Lauersen M.D. Ph.D

Dr. Susan Love's Menopause and Hormone Book: Making Informed Choices
by Susan M. Love, Karen Lindsey

Intimacy After Cancer: A Woman's Guide
by Dr. Sally Kydd, Dana Rowett

Living in the Postmastectomy Body: Learning to Live in and Love Your Body Again
by Rebecca L. Zuckweiler

Not Just One in Eight: Stories of Breast Cancer Survivors and Their Families
by Barbara F. Stevens

Speak the Language of Healing: A New Approach to Breast Cancer
by Susan Kuner, Carol Matzkin Orsborn, Linda Quigley, Karen Leigh Stroup

The Breast Cancer Prevention and Recovery Diet
by Suzannah Olivier

A Woman's Decision: Breast Care, Treatment and Reconstruction
by Karen Berger, John Bostwick III M.D.

Spanish-language Resources

American Cancer Society
Website: http://www.cancer.org/docroot/ESP/ESP_0.asp
American Cancer Society
Hotline: 1-800-ACS-2345

Comprehensive Health Enhancement Support System (CHESS) "Living with Breast Cancer"
Website: https://chess.wisc.edu/espanol/Home/Home.aspx
Hotline: 1-800-480-9223
Email: https://chess.wisc.edu/espanol/Comments/Comment.aspx

Living Beyond Breast Cancer Medical Issues
Website: http://www.lbbc.org/section-content.asp?scid=176&final=1&c=§ion_tag=L&t=LINK
Address: 354 West Lancaster Avenue., Suite 224
Haverford, PA 19041
Phone: 484-708-1550
Email: mail@lbbc.org