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What is it?
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 231,840 cases of invasive breast cancer will be diagnosed in 2015, according to the American Cancer Society (ACS). Though an estimated 40,290 women will die from breast cancer, there are more than 2.8 million breast cancer survivors in the United States, according to the ACS.
Breast cancer rates increased for about two decades and then started decreasing in 2000, dropping 7 percent between 2002 and 2003. This drop was thought to be a result of the decline in hormone replacement therapy in post-menopausal women that occurred after results of the Women's Health Initiative came out in 2002, which linked use of hormone therapy to increased risk of both breast cancer and heart disease.
Rates of breast cancer have been stable in recent years in white women and increased slightly in African American women. The rates among Asian American and Hispanic women are significantly lower than rates among white and African American women, though the rate among Asian Americans has risen in recent years.
Breast cancer is a disease in which malignant (cancerous) cells are found in breast tissue. 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.
One of the most important factors when it comes to breast cancer is whether the cancer is invasive or noninvasive. Noninvasive (in situ) cancers are confined to the ducts or lobules and have not spread to surrounding tissues or other parts of the body. Noninvasive cancers can develop into more serious invasive tumors. Invasive breast cancer has spread outside the milk duct and into the normal tissue inside the breast. Whether a breast cancer is invasive or noninvasive determines treatment and prognosis.
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 noninvasive 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 common subgroup of noninvasive 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 of invasive breast cancer. 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 3 to 5 percent of all breast cancers and involves a distinct boundary between tumor tissue and normal tissue. These tumors are called "medullary" because they resemble the grayish soft tissue of the brainstem, called the medulla. Medullary tumors are usually small, but the cells are frequently high grade, which means they look very different from normal cells and/or they divide rapidly. Medullary tumors are also often "triple-negative," which means they test negative for estrogen and progesterone receptors, as well as the HER2/neu protein. 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 2 percent of all breast cancers fall into this category. The prognosis is usually good.
- Paget's disease. A rare breast cancer in the ducts beneath the nipple accounting for only 1 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 1 to 3 percent of all cases. Skin over the breast appears acutely inflamed and swollen because skin lymph vessels are blocked by cancer. The skin resembles the peel of an orange.
- Triple-negative breast cancer. This type of breast cancer, usually invasive ductal carcinoma, has cells that lack receptors for the hormones estrogen and progesterone, and it does not express a specific protein called HER2, which makes tumors grow quickly. Triple-negative breast cancers tend to occur in younger women and African-American women and spread more quickly than most other breast cancer types.
- Metaplastic carcinoma. Also called carcinoma with metaplasia, this is a very rare type of invasive ductal breast cancer. These tumor cells make tissue not normally found in the breast such as bone and even cartilage and are treated like invasive ductal cancer.
- Papillary carcinoma. This type of breast cancer, which can be separated into noninvasive and invasive types, includes cells arranged in small, fingerlike projections. These cancers are more common in older women and make up fewer than 1 percent of all breast cancers.
- Mixed tumors. Mixed breast tumors contain a variety of cell types, such as invasive lobular breast cancer combined with invasive ductal cancer.
- Adenoid cystic carcinoma (adenocystic carcinoma). These breast cancers have both cylinder-like (cystic) and glandular (adenoid) features and make up less than 1 percent of breast cancers. Because they rarely spread to the lymph nodes and distant areas, these tumors usually have a very good prognosis.
- Phyllodes tumor. A very rare form of breast tumor, phyllodes tumor forms in the connective tissue of the breast, called the stroma. Phyllodes tumors are usually benign but may be malignant in rare cases, and the malignant form can spread (metastasize).
- Angiosarcoma. This form of breast cancer begins in cells that line blood vessels or lymph vessels. It rarely forms in the breast, but a risk factor for this is prior radiation treatment.
Your risk of developing invasive breast cancer at some time during your lifetime is a little less than one in eight (about 12 percent). This sounds high, but if you consider the term "lifetime," it helps put your risk in perspective. It means that one in 227 women will be diagnosed with breast cancer at age 30; one in 68 at age 40; one in 42 at age 50; one in 28 at age 60; and one in 26 at age 70. 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.
Your risk is higher if you have:
- A family history of breast cancer, specifically, a first-degree relative who has had it (mother, sister, daughter)
- 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
- Had radiation to the chest before the age of 40, particularly if it was given in adolescence
- Li-Fraumeni syndrome, Cowden syndrome, Peutz-Jeghers syndrome, are a carrier of ataxia telangiectasia (AT) gene, have a CDH1 mutation or have a first-degree relative with one of these syndromes.
- Lobular carcinoma in situ (LCIS), which 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 a seven to 10 times higher risk of developing invasive breast cancer.
- A biopsy-confirmed atypical lobular hyperplasia (ALH), which is a noncancerous breast disease characterized by the growth of abnormal cells. ALH may be discovered when a biopsy is done for a lump or to examine an abnormal area found on the mammogram.
- Diethylstibestrol (DES) exposure: Between the years of 1940 and 1960, some pregnant women were given the drug DES to lower their changes of miscarriage. Women who took DES have a slightly increased risk of developing breast cancer, as do women whose mother's took DES when they were pregnant with them.
- Dense breast tissue: Some women have dense breast tissue—more glandular and fibrous tissue and less fatty tissue. Women with dense breast tissue on mammograms have a 1.2 to 2 times higher risk of breast cancer than women with average breast density. Things that can affect breast density include age, certain medications, including hormone replacement therapy, genetics, menopausal status, and pregnancy.
- Early menstruation (beginning at 12 or younger) or late menopause: Women who have had more menstrual cycles in their lives because they started menstruating early (before age 12) or went through menopause later (after 55) have a slightly higher risk of breast cancer, possibly due to a longer lifetime exposure to the hormones progesterone and estrogen.
- Never had children or had your first baby after age 30: Women who never had children or who had their first child after 30 have a slightly higher risk of breast cancer than women who had children before age 30. However, the effect of pregnancy is different depending on the type of breast cancer. In fact, for certain types of breast cancer known as triple negative breast cancer, pregnancy seems to increase risk.
- Have used hormone therapy for a long time: Studies have shown using combined hormone replacement therapy (estrogen and progesterone) have an increased risk of developing breast cancer. Hormone replacement therapy may also increase risk of dying from breast cancer. Taking estrogen alone does not appear to increase breast cancer risk.
- Drink alcohol: According to the American Cancer Society, drinking alcohol is clearly linked to increased risk of breast cancer, and that risk increases with the amount of alcohol you consume. Women who consume one alcoholic beverage a day have a slightly increased risk compared with non-drinkers. Women who drink two to five drinks a day have about 1.5 times the risk of women who do not drink. Consuming excessive amounts of alcohol is also linked to increased risk of developing a number of other cancer types.
- Use hormonal birth control: Some studies have found women who use birth control pills or Depot-medroxyprogesterone acetate (DMPA; Depo-Provera) have a slightly increased risk of breast cancer compared to women who never used them. For women using DMPA, that risk doesn't seem to be increased if they used the drug more than five years ago.
- Are overweight or obese: Being overweight or obese after menopause increases risk of breast cancer. After menopause, when the ovaries stop making estrogen, most estrogen comes from fat tissue, and having excess fat tissue after menopause raises estrogen levels and therefore, breast cancer risk. The link between overweight and obesity and breast cancer risk is complex, however. Risk seems to be elevated for women who gained weight as adults but not for women who have been overweight since childhood.
Your risk may be higher if you:
- Smoke: For a long time, studies found no link between cigarette smoking and increased breast cancer risk. More recent studies have started to show a link between long-term heavy smoking and a higher risk of breast cancer, however. The 2014 U.S. Surgeon General's report on smoking stated there is "suggestive but not sufficient" evidence that smoking increases breast cancer risk.
- Work the night shift: Some studies have shown that women who work the night shift may have increased risk of breast cancer. The effect may be due to shifting levels of certain hormones, including melatonin, related to staying awake at night.
- Eat a poor diet: A number of studies have looked at the relationship between diet and breast cancer risk. Some show diet may play a role; for example, one recent study showed a link between high intake of red meat and increased breast cancer risk. Other studies have found no link between what a woman eats and her risk for breast cancer. With that being said, most studies have found breast cancer rates are lower in areas where women eat a diet low in total fat and saturated fat, and lowering your intake of these fats lowers your risk for other types of cancer and is good for your overall health as well.
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.
The American Cancer Society (ACS) and the United States Preventive Services Task Force (USPSTF) both recommend that, beginning at age 40, women at average risk for breast cancer should make their own choice about getting an annual mammogram, based on consultation with their health care providers about personal risks and benefits. The ACS recommends women 45 to 54 get annual mammograms, and that women 55 and older get a mammogram every two years. The ACS suggests screenings continue as long as you are in good health and expect to live 10 years or more. The USPSTF says mammography is of greatest benefit to women between ages 40 and 74. Women 75 and older should talk with their health care providers.
If you are at high risk for developing breast cancer, the ACS suggests you start getting an MRI and mammogram annually. 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.
HealthyWomen recommends that you ask your health care professional about breast cancer screening recommendations with your personal health history in mind.
Breast self-exam (BSE) is an option for women age 20 and older. Although BSE isn't specifically recommended for breast cancer screening, many women choose to examine their own breasts regularly, which is a good idea. Research has shown that BSE plays a small role in breast cancer detection compared with finding a breast lump 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.
Women who examine their own breasts should keep in mind that breast changes can occur with pregnancy, aging, menopause, during menstrual cycles or when they are taking birth control pills or other hormones.
Ask your health care professional to show you how to perform a BSE correctly or check the American Cancer Society website (www.cancer.org) for detailed instructions. The procedure for doing BSE is different from previous guidelines. There is now evidence that the right amount of pressure, the pattern of coverage of the breast and the position (lying down is best) increase a woman's ability to feel abnormalities. 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.
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 and Clinical Breast Exams
A mammogram is a specialized X-ray of your breasts from various angles. Although it doesn't usually hurt, a mammogram can be uncomfortable or 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.
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.
A clinical breast exam (CBE) is a manual examination of the breasts by a health care professional to check for any suspicious masses. Due to lack of evidence of clear benefit, the ACS no longer recommends regular CBE or breast self-exams. However, all women should be familiar with how their breasts normally look and feel and report any changes to their health care provider.
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.
Magnetic resonance imaging (MRI) uses magnetic fields to show differences between normal and abnormal tissue. Most women at high risk for breast cancer should get both a mammogram and an MRI annually starting at an age determined by the woman's health care professional and continue for as long as a woman is in good health.
For an MRI scan, you lie in a specially designed structure that houses the magnetic field. Contrast material is injected into your vein, and the MRI image shows the dye as it passes 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.
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 can be 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 staging according to the American Cancer Society and the American Joint Committee on Cancer (AJCC), TNM system (7th edition), where T stands for tumor category, N stands for nearby lymph nodes, and M stands for metastasis.
- Stage 0: Tis, N0, M0: Carcinoma in situ: About 20 percent of breast cancers are very early cancers, sometimes called ductal carcinoma in situ (DCIS).
- Stage 1A: T1, N0, M0: The tumor is 2 centimeters or 3/4 of an inch or less across (T1) and has not spread to the lymph nodes (N0) or distant sites (M0).
- Stage IB: T0 or T1, N1mi, M0: The tumor is 2 centimeters or less across or is not found in the breast (T0 or T1). There are micrometastases in one to three axillary lymph nodes, and the cancer in the lymph nodes is greater than 0.2 mm across and/or more than 200 cells but no larger than 2mm (N1mi). The cancer has not spread to distant sites (M0).
- Stage IIA: One of the following applies:
- T0 or T1, N1 (but not N1mi), M0: The tumor is 2 cm or less across or is not found (T1 or T0) and either:
—The cancer has spread to between one and three axillary lymph nodes, with cancer in the lymph nodes larger than 2 mm across (N1a),
—Tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy (N1b),
—The cancer has spread to between one and three lymph nodes under the arm and to internal mammary lymph nodes (found on sentinel lymph node biopsy) (N1c).
- T2, N0, M0: The tumor is larger than 2 cm but less than 5 cm across (T2) and hasn't yet spread to the lymph nodes (N0).
The cancer hasn't spread to distant sites (M0).
- Stage IIB:One of the following applies:
- T2, N1, M0: The tumor is larger than 2 cm but less than 5 cm across (T2). Cancer has spread to between one and three axillary lymph nodes and/or tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy (N1). The cancer hasn't yet spread to distant sites (M0).
- T3, N0, M0: The tumor is larger than 5 cm across but has not grown into the chest wall or skin and has not spread to lymph nodes (T3, N0). The cancer hasn't spread to distant sites (M0).
- Stage IIIA: One of the following applies:
- T0 to T2, N2, M0: The tumor is not more than 5 cm across, or it cannot be found (T0 to T2). Cancer has spread to between four and nine axillary lymph nodes, or it has enlarged the internal mammary lymph nodes (N2). The cancer hasn't spread to distant sites (M0).
- T3, N1 or N2, M0: The tumor is larger than 5 cm across but has not grown into the chest wall or skin (T3). It has spread to between one and nine axillary nodes or to internal mammary nodes (N1 or N2). The cancer hasn't spread to distant sites (M0).
- Stage IIIB: T4, N0 to N2, M0: The tumor has grown into the chest wall or skin (T4), and one of the following applies:
- It has not spread to the lymph nodes (N0).
- Cancer has spread to between one and three axillary lymph nodes and/or tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy (N1).
- Cancer has spread to between one and nine axillary lymph nodes, or it has enlarged the internal mammary lymph nodes (N2).
The cancer hasn't spread to distant sites (M0).
Inflammatory breast cancer is classified as T4d and is at least stage IIIB. If the cancer has spread to many nearby lymph nodes (N3), it could be stage IIIC, and if it has spread to distant lymph nodes or organs (M1) it would be stage IV.
- Stage IIIC: any T, N3, M0: The tumor is any size (or can't be found), and one of the following applies:
- Cancer has spread to the lymph nodes under the clavicle (collar bone) (N3).
- Cancer has spread to 10 or more axillary lymph nodes (N3).
- Cancer has spread to the lymph nodes above the clavicle (N3).
- Cancer involves axillary lymph nodes and has enlarged the internal mammary lymph nodes (N3).
- Cancer has spread to four or more axillary lymph nodes, and tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy (N3).
The cancer hasn't spread to distant sites (M0).
- Stage IV: any T, any N, M1: The cancer can be any size (any T) and may or may not have spread to nearby lymph nodes (any N). Cancer has spread to distant organs or to lymph nodes far from the breast (M1). The most common sites of spread are the bone, liver, brain, or lung.
- 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.
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 (also called partial mastectomy or segmental mastectomy) with sentinel lymph node biopsy technique described below. Also known as excisional biopsy or wide excision, lumpectomy is a breast-conserving surgical procedure.
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, a dissection or sampling of an axillary lymph node or nodes (a large group of lymph nodes located under the armpit or axilla) should be performed for invasive forms of the disease. A new technique called sentinel lymph node sampling takes one to three lymph nodes from under the arm. These lymph nodes are found by injecting a dye into the breast and looking for the first lymph node that picks up this dye. The surgeon can then remove the smallest number of lymph nodes possible. The idea is that if a lymph node is positive for cancer, it is most likely in the sentinel lymph node.
A mastectomy is another common surgical treatment for invasive cancer, and there are two primary types:
- Simple or total mastectomy: The entire breast is removed, including breast tissue, skin, areola and nipple, but not the chest tissue underneath.
- Modified radical mastectomy: The entire breast is removed along with underarm lymph nodes and sometimes the lining over the chest muscles and, more rarely, part of the chest wall muscle. This may be recommended if your tumor is large or if it is your preference.
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); whether there is a protein called HER2, which makes tumors grow more quickly; 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 may also start about 12 weeks before surgery to shrink the tumor and make it easier to surgically remove (called neoadjuvant therapy). It includes chemotherapy and/or hormone 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; fulvestrant (Faslodex), a drug that works similarly to tamoxifen but eliminates the estrogen receptor instead of blocking it; toremifene (Fareston), a drug that is similar to tamoxifen but is only approved to treat metastatic breast cancer, or an aromatase inhibitor, such as anastrozole (Arimidex), letrozole (Femara) or exemestane (Aromasin). Aromatase inhibitors stop estrogen production in post-menopausal women.
Several studies have compared aromatase inhibitors with tamoxifen as adjuvant therapy in post-menopausal women with breast cancer and found that aromatase inhibitors better reduce the risk of cancer recurrence than using tamoxifen by itself for five years. The drug schedules that appear to be the most helpful include the following:
- Tamoxifen for two to three years followed by an aromatase inhibitor to complete five years of total treatment
- Tamoxifen for five years, followed by an aromatase inhibitor for five years
- An aromatase inhibitor for five years
For post-menopausal women with hormone receptor-positive breast cancers, experts recommend using aromatase inhibitors as part of adjuvant therapy. Researchers are now investigating the best way to give these drugs, whether it's before or after tamoxifen or using them for five years or longer.
Tamoxifen also carries some risks, however, including increased risk of stroke, pulmonary emboli and fatal uterine cancers. Patients should discuss these risks with their health care professionals. In most cases, the benefits of using tamoxifen as a treatment for breast cancer outweigh the risks.
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.
- Radiation therapy should be used in people having a lumpectomy. It also may be 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. It also may be used in women with high-risk factors such as lymphovascular involvement. For all women—even those with high risk factors—radiation therapy is considered on an individual basis. Such treatment can help destroy breast cancer cells that may have been left behind in the area where the breast was.
Radiation comes in two forms—external radiation, where radiation is delivered as external beams outside the body, and internal radiation, where radioactive seeds or pellets are placed into a device in the affected area of breast tissue.
External radiation is the more popular choice. The standard course of external radiation treatment is five days a week for five to six weeks for women who've had a mastectomy.
When radiation is used as part of breast conservation therapy, in conjunction with a lumpectomy, it is usually used for three weeks or six weeks.
Some doctors use more accelerated schedules, including those that give slightly larger daily doses for only three weeks, the so-called Canadian fractionated schedule or hypofractionated radiation therapy. Other new techniques are 3-D conformal radiotherapy and intensity-modulated radiation therapy, both of which give radiation that better targets the area where the tumor was, sparing normal tissue such as the heart from residual effects.
Internal radiation is also called brachytherapy. It can be used as part of breast conservation therapy, either as a boost before or after five weeks of external beam therapy or on its own through a brachytherapy catheter. The brachytherapy catheter delivers small radioactive pellets directly into the lumpectomy cavity. This treatment is called accelerated partial breast radiation. It is given twice a day for five days, with treatments separated by six hours. If the person is not a candidate for this type of brachytherapy, similar therapy can be done through small fields of external radiation, though less tissue will be spared. Again the treatments are twice a day for five days. At the last treatment, the catheter device is removed.
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.
Other factors that help determine treatment and prognosis include the following:
- Tumor size. In general, patients with small tumors have a better prognosis than do patients with large tumors.
- Breast cancer 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+). Tumors that contain progesterone receptors are said to be progesterone receptor positive (PR+). About two-thirds of breast tumors contain at least one of these receptors. 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.
- Gene patterns. Looking at patterns of a number of different genes at the same time (called gene expression profiling) can help predict how likely an early stage breast cancer is to recur after initial treatment. There are two tests of gene patterns currently available: the Oncotype DX and the MammaPrint.
Other tests may be performed to check the growth rate of the cancer and to help determine appropriate therapy.
In addition, about one in five women with breast cancer have an excess of a protein called HER2/neu (or just HER2), which makes tumors grow quickly. A number of drugs are used to target the HER2 protein, including
- Trastuzumab (Herceptin)
- Pertuzumab (Perjeta)
- Ado-trastuzumab emtansine (Kadcyla)
- Lapatinib (Tykerb)
Pregnancy and Breast Cancer
Breast cancer can occur during pregnancy or within the first year after giving birth. Unfortunately, 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.
There is no known way to prevent breast cancer. But there are some things you can do to reduce your risk of breast cancer.
For women with a known increased risk for breast cancer, the drugs tamoxifen and raloxifene may help reduce that risk. Drugs called aromatase inhibitors may also reduce risk. The aromatase inhibitor exemestane (Aromasin) is recommended by the American Society of Clinical Oncology for primary risk reduction among postmenopausal women who are at increased risk for invasive breast cancer. However, aromatase inhibitors are still being studied and aren't yet FDA approved for breast cancer prevention. Additional compounds, including some dietary supplements, are also currently being studied. So far, none of them show promise.
If you have a high risk for breast cancer, talk to your health care professional about drugs that may 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 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. To find an FDA certified mammography facility in your area, go to: www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMQSA/mqsa.cfm.
- 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.
- 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
- An estimated 231,840 new cases of invasive breast cancer will be diagnosed in 2015. Approximately 40,290women will die from breast cancer in 2015. Breast cancer is the most common type of cancer in women (besides skin cancer) and the second-leading cause of cancer death in women.
- The five-year relative survival rate for localized breast cancer has increased from 72 percent in the 1940s to about 100 percent for stage 0 and 1, 93 percent for stage II,, 72 percent for III, and 22 percent for stage IV.
- 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.
- 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.
- 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.
- 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.
- Some mammography centers 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.
- 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, it means that one in 227 women will be diagnosed with breast cancer at age 30; one in 68 at age 40; one in 42 at age 50; one in 28 at age 60; and one in 26 at age 70.
- Some breast cancer cases are the result of a mutation in the BRCA 1 or 2 genes, which can be inherited. Hereditary breast cancer makes up approximately 5 to 10 percent of all breast cancer. 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.
- 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.
What is my risk for developing breast cancer?
My mother had breast cancer. Will I develop it, too?
What can I do to reduce my risks for developing breast cancer?
What are the symptoms of breast cancer?
What are dense breasts?
How is breast cancer diagnosed?
Are breast self-exams really worth doing? Will you show me how to do one?
How often and when should I do a breast self-exam?
What is a clinical breast exam? How often do I need to have one?
What is a screening mammogram? Should I have one? Does it hurt?
What is a diagnostic mammogram?
Are low-cost or free mammograms available? I'm not sure I can afford one.
What is breast tomosynthesis?
Can breast cancer be treated? What treatments are available?
I've been taking birth control pills for years. Do they increase my risk for developing breast cancer?
Does postmenopausal hormone replacement therapy cause breast cancer?
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 chemotherapy and/or hormonal therapy. Five-year survival after treatment for stage 0 and stage 1 breast cancers is close to 100 percent.
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 and annual mammograms and MRIs. Breast cancer incidence increases with age, rising sharply after age 40. About 80 percent of invasive breast cancer occurs in women over age 50.
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.
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.
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 an increased 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.
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.
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 5 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 a 65 percent chance of developing breast cancer and 39 percent chance of developing ovarian cancer by age 70.
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.
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.
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.
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 feel pressured 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.
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.
Hormone replacement therapy increases breast cancer risk
Taking combined estrogen-progestin hormone replacement 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.
Free and low-cost mammograms available
The Affordable Care Act mandates coverage of mammograms for breast cancer screening without co-pay or deductible in plans that started after August 1, 2012.
The cost of mammography varies from state to state. Most health insurers and Medicare cover mammography, an X-ray screening for breast cancer. If you are not insured and cannot afford mammography, call the American Cancer Society, (800-ACS-2345), the Susan G. Komen organization (877-465-6636), 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 through its website www.nationalbreastcancer.org or call the U.S. Centers for Disease Control and Prevention (CDC) at 1-800-CDC-INFO (800-232-4636). October is National Breast Cancer Awareness Month, when many mammography facilities offer reduced fees and extended hours. If you need an October appointment, it helps to call in September to reserve a slot.
For more information on mammogram coverage, click here.
Organizations and Support
Organizations and Support
African American Breast Cancer Alliance
Address: P.O. Box 8981
Minneapolis, MN 55408
American Cancer Society (ACS)
Address: 250 Williams Street
Atlanta, GA 30303
Hotline: 1-800-ACS-2345 (1-800-227-2345)
Breast Cancer Action
Address: 55 New Montgomery St, Suite 323
San Francisco, CA 94105
Hotline: 1-877-2STOPBC (1-877-278-6722)
Breast Cancer Connections
Address: 390 Cambridge Avenue
Palo Alto, CA 94306
Address: 7 East Lancaster Avenue, 3rd Floor
Ardmore, PA 19003
Breast Cancer Research Foundation
Address: 60 East 56th Street, 8th Floor
New York, NY 10022
Hotline: 1-866-FIND-A-CURE (346-3228)
Cancer Care, Inc.
Address: 275 Seventh Ave., Floor 22
New York, NY 10001
Hotline: 1-800-813-HOPE (1-800-813-4673)
Cancer Information and Counseling Line (CICL)
Address: AMC Cancer Research Center
1600 Pierce Street
Denver, CO 80214
Cancer Support Community
Address: Gilda's Club Worldwide
48 Wall Street, 11th Floor
New York, NY 10005
FDA Breast Implant Information Hotline
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
Address: U.S. Food and Drug Administration
5600 Fishers Lane
Rockville, MD 20857-0001
FORCE: Facing Our Risk of Cancer Empowered
Address: 16057 Tampa Palms Blvd. W, PMB #373
Tampa, FL 33647
Living Beyond Breast Cancer (LBBC)
Address: 354 West Lancaster Ave., Suite 224
Haverford, PA 19041
Mothers Supporting Daughters with Breast Cancer
Address: 25235 Fox Chase Drive
Chestertown, MD 21620
National Breast and Cervical Cancer Early Detection Program
4770 Buford Hwy, NE MS K-64
Atlanta, GA 30341
Hotline: 1-800-CDC-INFO (1-800-232-4636)
National Breast Cancer Coalition (NBCC)
Address: 1101 17th Street, NW, Suite 1300
Washington, DC 20036
National Cancer Institute (NCI)
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)
Address: 1010 Wayne Ave., Suite 770
Silver Spring, MD 20910
Hotline: 1-877-NCCS-YES (1-877-622-7937)
Prevent Cancer Foundation
Address: 1600 Duke Street, Suite 500
Alexandria, VA 22314
SHARE - Self-Help for Women with Breast or Ovarian Cancer
Address: 1501 Broadway, Suite 704A
New York, NY 10036
Address: 1086 Teaneck Road, Suite 3A
Teaneck, NJ 07666
Sister's Network Inc.
Address: 2922 Rosedale St
Houston, TX 77004
Support Connection - Breast and Ovarian Cancer Support
Address: 360 Underhill Ave., 2nd Floor
Yorktown, NY 10598
Susan G. Komen for the Cure
Address: 5005 LBJ Freeway, Suite 250
Dallas, TX 75244
Hotline: 1-877-GO-KOMEN (1-877-465-6636)
Women's Cancer Resource Center
Address: 5741 Telegraph Avenue
Oakland, CA 94609
Y-ME National Breast Cancer Organization
Address: 135 S. LaSalle St., Suite 2000
Chicago, IL 60603
Hotline: 1-800-221-2141 (English) 1-800-986-9505 (Español)
Young Survival Coalition
Address: 61 Broadway, Suite 2235
New York, NY 10006
Hotline: 1-877-YSC-1011 (1-877-972-1011)
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.
American Cancer Society
American Cancer Society
Comprehensive Health Enhancement Support System (CHESS) "Living with Breast Cancer"
Living Beyond Breast Cancer Medical Issues
Address: 354 West Lancaster Avenue., Suite 224
Haverford, PA 19041
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Last date updated: 2016-03-23
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