Breast cancer (patient information)

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 * Associate Editor(s)-In-Chief: Jinhui Wu, M.D.; Assistant Editor(s)-In-Chief: Meagan E. Doherty

Overview
Breast cancer is cancer that forms in tissues of the breast, usually the ducts (tubes that carry milk to the nipple) and lobules (glands that make milk). It occurs in both men and women, although male breast cancer is rare. Usual symptoms of breast cancer include swelling of all or part of a breast, skin irritation or dimpling, breast or nipple pain, nipple retraction, redness, scaliness, or thickening of the nipple or breast skin and a discharge other than breast milk. Treatments include surgery, radiation therapy, chemotherapy, hormone therapy and targeted therapy. Prognosis of breast cancer has improved greatly in recent years.

What are the symptoms of Breast cancer?
Symptoms of breast cancer may include a lump in the breast, a change in size or shape of the breast or discharge from a nipple.


 * Swelling of all or part of a breast (even if no distinct lump is felt)
 * Skin irritation or dimpling
 * Breast or nipple pain
 * Nipple retraction (turning inward)
 * Redness, scaliness, or thickening of the nipple or breast skin
 * A discharge other than breast milk

Other health problems may also cause these symptoms. Only a doctor can tell for sure. A person with any of these symptoms should tell the doctor so that the problems can be diagnosed and treated as early as possible.

Who is at highest risk?
No one knows the exact causes of breast cancer. Doctors often cannot explain why one woman develops breast cancer and another does not. They do know that bumping, bruising, or touching the breast does not cause cancer. And breast cancer is not contagious. You cannot "catch" it from another person.

Research has shown that women with certain risk factors are more likely than others to develop breast cancer. A risk factor is something that may increase the chance of developing a disease.

Age: The chance of getting breast cancer goes up as a woman gets older. Most cases of breast cancer occur in women over 60. This disease is not common before menopause.

Personal history of breast cancer: A woman who had breast cancer in one breast has an increased risk of getting cancer in her other breast.

Family history: A woman's risk of breast cancer is higher if her mother, sister, or daughter had breast cancer. The risk is higher if her family member got breast cancer before age 40. Having other relatives with breast cancer (in either her mother's or father's family) may also increase a woman's risk.

Certain breast changes: Some women have cells in the breast that look abnormal under a microscope. Having certain types of abnormal cells (atypical hyperplasia and lobular carcinoma in situ [LCIS]) increases the risk of breast cancer.

Gene changes: Changes in certain genes increase the risk of breast cancer. These genes include BRCA1, BRCA2, and others. Tests can sometimes show the presence of specific gene changes in families with many women who have had breast cancer. Health care providers may suggest ways to try to reduce the risk of breast cancer, or to improve the detection of this disease in women who have these changes in their genes. NCI offers publications on gene testing.

Reproductive and menstrual history:
 * The older a woman is when she has her first child, the greater her chance of breast cancer.
 * Women who had their first menstrual period before age 12 are at an increased risk of breast cancer.
 * Women who went through menopause after age 55 are at an increased risk of breast cancer.
 * Women who never had children are at an increased risk of breast cancer.
 * Women who take menopausal hormone therapy with estrogen plus progestin after menopause also appear to have an increased risk of breast cancer.
 * Large, well-designed studies have shown no link between abortion or miscarriage and breast cancer.

Race: Breast cancer is diagnosed more often in white women than Latina, Asian, or African American women.

Radiation therapy to the chest: Women who had radiation therapy to the chest (including breasts) before age 30 are at an increased risk of breast cancer. This includes women treated with radiation for Hodgkin's lymphoma. Studies show that the younger a woman was when she received radiation treatment, the higher her risk of breast cancer later in life.

Breast density: Breast tissue may be dense or fatty. Older women whose mammograms (breast x-rays) show more dense tissue are at increased risk of breast cancer.

Taking DES (diethylstilbestrol): DES was given to some pregnant women in the United States between about 1940 and 1971. (It is no longer given to pregnant women.) Women who took DES during pregnancy may have a slightly increased risk of breast cancer. The possible effects on their daughters are under study.

Being overweight or obese after menopause: The chance of getting breast cancer after menopause is higher in women who are overweight or obese.

Lack of physical activity: Women who are physically inactive throughout life may have an increased risk of breast cancer. Being active may help reduce risk by preventing weight gain and obesity.

Drinking alcohol: Studies suggest that the more alcohol a woman drinks, the greater her risk of breast cancer.

When to seek urgent medical care?
See your health care provider about a breast change when you have:
 * A lump in or near your breast or under your arm
 * Thick or firm tissue in or near your breast or under your arm
 * Nipple discharge or tenderness
 * A nipple pulled back (inverted) into the breast
 * Itching or skin changes such as redness, scales, dimples, or puckers
 * A change in breast size or shape

Diagnosis
If you have a symptom or screening test result that suggests cancer, your doctor must find out whether it is due to cancer or to some other cause. Your doctor may ask about your personal and family medical history. You may have a physical exam. Your doctor also may order a mammogram or other imaging procedure. These tests make pictures of tissues inside the breast. After the tests, your doctor may decide no other exams are needed. Your doctor may suggest that you have a follow-up exam later on. Or you may need to have a biopsy to look for cancer cells.

Clinical Breast Exam Your health care provider feels each breast for lumps and looks for other problems. If you have a lump, your doctor will feel its size, shape, and texture. Your doctor will also check to see if it moves easily. Benign lumps often feel different from cancerous ones. Lumps that are soft, smooth, round, and movable are likely to be benign. A hard, oddly shaped lump that feels firmly attached within the breast is more likely to be cancer.

Diagnostic Mammogram Diagnostic mammograms are x-ray pictures of the breast. They take clearer, more detailed images of areas that look abnormal on a screening mammogram. Doctors use them to learn more about unusual breast changes, such as a lump, pain, thickening, nipple discharge, or change in breast size or shape. Diagnostic mammograms may focus on a specific area of the breast. They may involve special techniques and more views than screening mammograms.

Ultrasound An ultrasound device sends out sound waves that people cannot hear. The waves bounce off tissues. A computer uses the echoes to create a picture. Your doctor can view these pictures on a monitor. The pictures may show whether a lump is solid or filled with fluid. A cyst is a fluid-filled sac. Cysts are not cancer. But a solid mass may be cancer. After the test, your doctor can store the pictures on video or print them out. This exam may be used along with a mammogram.

Magnetic Resonance Imaging Magnetic resonance imaging (MRI) uses a powerful magnet linked to a computer. MRI makes detailed pictures of breast tissue. Your doctor can view these pictures on a monitor or print them on film. MRI may be used along with a mammogram.

Biopsy Your doctor may refer you to a surgeon or breast disease specialist for a biopsy. Fluid or tissue is removed from your breast to help find out if there is cancer. Some suspicious areas can be seen on a mammogram but cannot be felt during a clinical breast exam. Doctors can use imaging procedures to help see the area and remove tissue. Such procedures include ultrasound-guided, needle-localized, or stereotactic biopsy. Doctors can remove tissue from the breast in different ways:


 * Fine-needle aspiration: Your doctor uses a thin needle to remove fluid from a breast lump. If the fluid appears to contain cells, a pathologist at a lab checks them for cancer with a microscope. If the fluid is clear, it may not need to be checked by a lab.
 * Core biopsy: Your doctor uses a thick needle to remove breast tissue. A pathologist checks for cancer cells. This procedure is also called a needle biopsy.
 * Surgical biopsy: Your surgeon removes a sample of tissue. A pathologist checks the tissue for cancer cells.
 * An incisional biopsy takes a sample of a lump or abnormal area.
 * An excisional biopsy takes the entire lump or area.

If cancer cells are found, the pathologist can tell what kind of cancer it is. The most common type of breast cancer is ductal carcinoma. Abnormal cells are found in the lining of the ducts. Lobular carcinoma is another type. Abnormal cells are found in the lobules.

Treatment options
Different types of treatment are available for patients with breast cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment. Four types of standard treatments are used:

Surgery Most patients with breast cancer have surgery to remove the cancer from the breast. Some of the lymph nodes under the arm are usually taken out and looked at under a microscope to see if they contain cancer cells.

Breast-conserving surgery, an operation to remove the cancer but not the breast itself, includes the following:
 * Lumpectomy: Surgery to remove a tumor (lump) and a small amount of normal tissue around it.
 * Partial mastectomy: Surgery to remove the part of the breast that has cancer and some normal tissue around it. This procedure is also called a segmental mastectomy.

Patients who are treated with breast-conserving surgery may also have some of the lymph nodes under the arm removed for biopsy. This procedure is called lymph node dissection. It may be done at the same time as the breast-conserving surgery or after. Lymph node dissection is done through a separate incision.

Other types of surgery include the following:


 * Total mastectomy: Surgery to remove the whole breast that has cancer. This procedure is also called a simple mastectomy. Some of the lymph nodes under the arm may be removed for biopsy at the same time as the breast surgery or after. This is done through a separate incision.
 * Modified radical mastectomy: Surgery to remove the whole breast that has cancer, many of the lymph nodes under the arm, the lining over the chest muscles, and sometimes, part of the chest wall muscles.
 * Radical mastectomy: Surgery to remove the breast that has cancer, chest wall muscles under the breast, and all of the lymph nodes under the arm. This procedure is sometimes called a Halsted radical mastectomy.

Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given radiation therapy, chemotherapy, or hormone therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to increase the chances of a cure, is called adjuvant therapy.

If a patient is going to have a mastectomy, breast reconstruction (surgery to rebuild a breast’s shape after a mastectomy) may be considered. Breast reconstruction may be done at the time of the mastectomy or at a future time. The reconstructed breast may be made with the patient’s own (nonbreast) tissue or by using implants filled with saline or silicone gel.

Radiation therapy Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Chemotherapy Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Hormone therapy Hormone therapy is a cancer treatment that removes hormones or blocks their action and stops cancer cells from growing. Hormones are substances produced by glands in the body and circulated in the bloodstream. Some hormones can cause certain cancers to grow. If tests show that the cancer cells have places where hormones can attach (receptors), drugs, surgery, or radiation therapy are used to reduce the production of hormones or block them from working. The hormone estrogen, which makes some breast cancers grow, is made mainly by the ovaries. Treatment to stop the ovaries from making estrogen is called ovarian ablation.

Hormone therapy with tamoxifen is often given to patients with early stages of breast cancer and those with metastatic breast cancer (cancer that has spread to other parts of the body). Hormone therapy with tamoxifen or estrogens can act on cells all over the body and may increase the chance of developing endometrial cancer. Women taking tamoxifen should have a pelvic exam every year to look for any signs of cancer. Any vaginal bleeding, other than menstrual bleeding, should be reported to a doctor as soon as possible.

Hormone therapy with an aromatase inhibitor is given to some postmenopausal women who have hormone-dependent breast cancer. Hormone-dependent breast cancer needs the hormone estrogen to grow. Aromatase inhibitors decrease the body's estrogen by blocking an enzyme called aromatase from turning androgen into estrogen.

For the treatment of early stage breast cancer, certain aromatase inhibitors may be used as adjuvant therapy instead of tamoxifen or after 2 or more years of tamoxifen. For the treatment of metastatic breast cancer, aromatase inhibitors are being tested in clinical trials to compare them to hormone therapy with tamoxifen.

Diseases with similar symptoms

 * Lipoma
 * Cyst
 * Breast abscess

Where to find medical care for Breast cancer?
Directions to Hospitals Treating Breast cancer

What to expect (Outlook/Prognosis)?
Survival rates for Breast Cancer
 * 80.4% of women with breast cancer survive after 5 years in the US 1983-90 (SEER)
 * Breast cancer survival rates by stage of disease:
 * 100% of women survive breast cancer if it is detected before it starts to spread in the US (The American Cancer Society)
 * 98% of women survive breast cancer if it is detected while it is smaller than 2cm in diameter and hasn’t spread in the US (The American Cancer Society)
 * 88% of women survive breast cancer if it is detected while it is 2-5cm in diameter and has spread to axillary lymph nodes in the US (The American Cancer Society)
 * 76% of women survive breast cancer if it is detected even over 5cm in diameter if it hasn’t spread to axillary lymph nodes in the US (The American Cancer Society)
 * 76% of women survive breast cancer if it is detected while it is 2-5cm in diameter and has spread to axillary lymph nodes in the US (The American Cancer Society)
 * 56% of women survive breast cancer if it is detected after it has spread to axillary lymph nodes and to axillary tissues in the US (The American Cancer Society)
 * 49% of women survive breast cancer if it is detected after it has attached itself to the chest wall and chest lymph nodes in the US (The American Cancer Society)
 * 16% of women survive breast cancer if it is detected after it has spread to other parts of the body such as bone, lung or liver in the US (The American Cancer Society)

Possible complications
You may experience side effects or complications from cancer treatment. For example, radiation therapy may cause temporary swelling of the breast (lymphedema), and aches and pains around the area.

Lymphedema may start 6 to 8 weeks after surgery or after radiation treatment for cancer.

It can also start very slowly after your cancer treatment is over. You may not notice symptoms until 18 to 24 months after treatment. Sometimes it can take years to develop.

Ask your doctor about the side effects you may have during treatment.

Prevention
The following protective factors may decrease the risk of breast cancer:

Exercise Exercising four or more hours a week may decrease hormone levels and help lower breast cancer risk. The effect of exercise on breast cancer risk may be greatest in premenopausal women of normal or low weight. Care should be taken to exercise safely, because exercise carries the risk of injury to bones and muscles.

Estrogen (decreased exposure) Decreasing the length of time a woman's breast tissue is exposed to estrogen may help prevent breast cancer. Exposure to estrogen is reduced in the following ways:


 * Pregnancy: Estrogen levels are lower during pregnancy. The risk of breast cancer appears to be lower if a woman has her first full-term pregnancy before she is 20 years old.
 * Breast-feeding: Estrogen levels may remain lower while a woman is breast-feeding.
 * Ovarian ablation: The amount of estrogen made by the body can be greatly reduced by removing one or both ovaries, which make estrogen. Also, drugs may be taken to lower the amount of estrogen made by the ovaries.
 * Late menstruation: Beginning to have menstrual periods at age 14 or older decreases the number of years the breast tissue is exposed to estrogen.
 * Early menopause: The fewer years a woman menstruates, the shorter the time her breast tissue is exposed to estrogen.

Selective estrogen receptor modulators Selective estrogen receptor modulators (SERMs) are drugs that act like estrogen on some tissues in the body, but block the effect of estrogen on other tissues. Tamoxifen is a SERM that belongs to the family of drugs called antiestrogens. Antiestrogens block the effects of the hormone estrogen in the body. Tamoxifen lowers the risk of breast cancer in women who are at high risk for the disease. This effect lasts for several years after drug treatment is stopped.

Taking tamoxifen increases the risk of developing other serious conditions, including endometrial cancer, stroke, cataracts, and blood clots, especially in the lungs and legs. The risk of developing these conditions increases with age. Women younger than 50 years who have a high risk of breast cancer may benefit the most from taking tamoxifen. Talk with your doctor about the risks and benefits of taking this drug.

Raloxifene is another SERM that helps prevent breast cancer. In postmenopausal women with osteoporosis (decreased bone density), raloxifene lowers the risk of breast cancer for women at both high risk and low risk of developing the disease. It is not known if raloxifene would have the same effect in women who do not have osteoporosis. Like tamoxifen, raloxifene may increase the risk of blood clots, especially in the lungs and legs, but does not appear to increase the risk of endometrial cancer.

Other SERMs are being studied in clinical trials.

Aromatase inhibitors Aromatase inhibitors lower the risk of new breast cancers in postmenopausal women with a history of breast cancer. In postmenopausal women, taking aromatase inhibitors decreases the amount of estrogen made by the body. Before menopause, estrogen is made by the ovaries and other tissues in a woman's body, including the brain, fat tissue, and skin. After menopause, the ovaries stop making estrogen, but the other tissues do not. Aromatase inhibitors block the action of an enzyme called aromatase, which is used to make all of the body's estrogen. Possible harms from taking aromatase inhibitors include osteoporosis and effects on brain function (such as talking, learning, and memory).

Prophylactic mastectomy Some women who have a high risk of breast cancer may choose to have a prophylactic mastectomy (the removal of both breasts when there are no signs of cancer). The risk of breast cancer is lowered in these women. However, it is very important to have a cancer risk assessment and counseling about all options for possible prevention before making this decision. In some women, prophylactic mastectomy may cause anxiety, depression, and concerns about body image.

Prophylactic oophorectomy Some women who have a high risk of breast cancer may choose to have a prophylactic oophorectomy (the removal of both ovaries when there are no signs of cancer). This decreases the amount of estrogen made by the body and lowers the risk of breast cancer. However, it is very important to have a cancer risk assessment and counseling before making this decision. The sudden drop in estrogen levels may cause the onset of symptoms of menopause, including hot flashes, trouble sleeping, anxiety, and depression. Long-term effects include decreased sex drive, vaginal dryness, and decreased bone density. These symptoms vary greatly among women.

Fenretinide Fenretinide is a type of vitamin A called a retinoid. When given to premenopausal women who have a history of breast cancer, fenretinide may lower the risk of forming a new breast cancer. Taken over time, fenretinide may cause night blindness and skin disorders. Women must avoid pregnancy while taking this drug because it could harm a developing fetus.