Breast Cancer

Introduction

Breast cancer is a common type of cancer in women.  It is a malignant (cancerous) tumor that begins from the cells in the breast.  Breast cancer can rarely develop in men, as well.  There are several different types of breast cancer, and they may develop in any part of the breast.  Early detection and treatment is very important because some forms of breast cancer are treatable.  Advancements in early detection methods and more tolerable cancer treatments have helped to reduce the number of breast cancer related deaths and improve quality of life.  Breast cancer is currently the leading cause of cancer death among Hispanic women and the second leading cause of cancer death among White, Black, Asian/Pacific Islander, and American Indian/Alaska Native women.  Although breast cancer treatments have come a long way over time, women still need to remain vigilant and should contact their doctor if they notice changes in their breasts.

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Anatomy

Both males and females have breasts, but they only develop in adult females.  The breast is covered by skin and supported by suspensory ligaments.  The nipple and areola consist of pigmented or darker colored skin than the rest of the breast.  The nipple contains muscle fibers.  The muscle fibers allow the nipple to become erect during lactation to enhance the flow of milk.  Lactation is the process of secreting milk from the breast to feed a baby.  The areola is the pigmented circle surrounding the nipple.  The areola contains glands that may act as a lubricant for a suckling baby.
 
A woman’s breast is composed of blood vessels, nerves, fatty tissue, connective tissue, lobules, and lymphatic vessels.  Lobules are glands that are capable of making breast milk.  A group of lobules form a lobe.  There are about 15-20 lobes in each breast.  Ducts or small tubes from the lobules merge to form lactiferous ducts that lead from the lobe to the nipple.  Just below the nipple, the lactiferous ducts form the lactiferous sinuses.  The lactiferous sinuses are reservoirs for milk during lactation.
 
The lymphatic vessels are tubes that carry lymph fluid.  Lymph fluid contains waste products, fats from breast milk, and immune system cells.  The lymphatic vessels lead to lymph nodes.  The lymph nodes filter the lymph fluid.  Most of the lymph nodes from the breasts are located in the under arm or armpit area.  They are termed axillary nodes. 
 
A healthy breast may contain abnormal growths or cysts that are benign (not cancerous).  Benign breast tumors do not spread outside of the breast.  Most benign breast lumps are fibrocystic tumors.  Fibrocystic tumors are benign fluid filled sacs located in the breast tissue.  They can develop scar tissue and cause swelling and discomfort.
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Causes

The exact cause of breast cancer is unknown and the subject of intense research.  Cancer occurs when cells grow abnormally and out of control, instead of dividing in an orderly manner.  Breast cancer originates in the breast and often forms a lump or tumor.  Cancerous breast lumps usually feel firm or hard and are painless.  There are several different types of breast cancer.  Breast cancer is labeled based on where it originated in the breast and if it could potentially spread.  Invasive types of breast cancer can spread to other parts of the body.  Noninvasive breast cancers are confined to the area they started in and do not spread to other parts of the body.
 
Some of the most common types of breast cancer include:
 
Lobular carcinoma in situ (LCIS):  LCIS is not a true cancer, but having LCIS increases a woman’s chance of getting cancer.  This condition begins in the milk-making glands but does not extend outside of the lobule.
Carcinoma in situ:  This is an early type of breast cancer that has not spread from where it started, usually in the ducts or lobules.
Ductal carcinoma in situ (DCIS): This type of breast cancer originates in and is confined to the ducts.  This is the most common type of noninvasive breast cancer.  Almost all women with DCIS can be cured.
Infiltrating invasive ductal carcinoma (IDC):  This is the most common type of breast cancer.  IDC originates in a milk passage or duct and spreads into the fatty tissue of the breast.  It is an invasive cancer that can also spread to other parts of the body. 
Infiltrating invasive lobular carcinoma (ILC):  This type of breast cancer originates in the milk glands or lobules and can spread to other parts of the body. 
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Symptoms

The most common symptom of breast cancer is a new lump or mass.  The lump may feel very firm or hard.  They are usually painless and have irregular borders.  A lump or mass may appear in the breast or armpit.
 
Your breast may look different.  Its size or shape may change.  It may appear swollen.  The color or texture of your breast, areola, or nipple may change.  The skin may appear dimpled, puckered, or retracted in.  Your skin may appear scaly, red, or irritated.  The symptoms may cause discomfort on just one breast.
 
Your nipple may be painful and look different.  It may turn inward or enlarge.  Your nipple may produce an abnormal discharge.  An abnormal discharge is fluid other than milk.  An abnormal discharge may look bloody, clear to yellow colored, green colored, or purulent, like pus.
 
Symptoms in men may include a lump, pain, or tenderness. 
 
Symptoms of advanced breast cancer include bone pain, weight loss, swelling of one arm, and skin sores.
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Diagnosis

Any breast change in women or men should be brought to their doctor’s attention.  Your doctor can begin to diagnose breast cancer after reviewing your medical history and conducting a physical examination.  You should tell your doctor about your symptoms and risk factors.  Your doctor will conduct a clinical breast exam (CBE) including your breasts, armpits, neck and chest area.  Your doctor will look at your breasts to see if they have changed in size or shape.  Your doctor will use the pads of his or her fingers to check for lumps or masses.  Your doctor may also recommend further tests.

A mammogram is a type of X-ray used to identify breast masses or tumors.  For this test, your breast is placed between two plates.  The two plates compress your breast to flatten and spread the tissue in order to obtain the best image possible.  This test may be uncomfortable, but only for a very brief period of time.  A mammogram may only tell if a tumor is present.  It cannot tell if a tumor is cancerous or not.

A breast ultrasound is used to determine if a breast lump is solid or fluid filled.  It is sometimes used with a mammogram to provide a better look at areas of concern.  For this test, an imaging device is gently moved across your skin.  Sound waves collected by the device create an image on a monitor for your doctor to examine.

A ductogram or galactogram is used to identify masses inside a duct and the cause of nipple discharge.  For this test, a substance is injected into the nipple and an X-ray is taken.  The substance outlines the shape of the duct on the X-ray for the doctor to examine.

If cancer is suspected on a mammogram, breast ultrasound, or ductogram, a biopsy will be conducted.  A biopsy takes a sample of breast tissue, cells, or fluid for examination.  There are several types of biopsies including needle aspiration and surgical biopsy.  Needle aspiration uses a fine needle to withdraw fluid out of the lump for testing.  Stereotactic core needle biopsies use a thicker needle to remove tissue samples.  Surgical biopsies remove all or part of a lump as well as some normal tissue around it.  Surgical biopsies are usually done on an outpatient basis.

Stereotactic breast biopsy may be an alternative to open surgical biopsy methods for some women.  Stereotactic breast biopsy is used to obtain a tissue sample of suspicious breast tissue for examination for cancer cells.  It is especially useful for diagnosing areas of breast tissue that appear suspicious on a mammogram, but that cannot be felt during a clinical breast examination.  This short outpatient procedure is performed with local anesthesia.  It uses a special mammography machine to pinpoint the suspicious area.  A vacuum assisted needle is used to remove the tissue samples.  Recovery time is brief and this biopsy method does not distort the breast tissue or make it difficult to read future mammograms.  Stereotactic breast biopsy methods are as accurate as traditional biopsy methods.

If your doctor suspects that your cancer has spread from your breasts to other parts of your body, more tests will be ordered.  These may include blood tests and imaging tests.  A chest X-ray can determine if the cancer has spread to your lungs.  A bone scan can determine if the cancer has spread to the bone.  Computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, and positron emission tomography (PET) scans are imaging tests that may also be used.  The CT scan is helpful for identifying cancer in the liver and other organs.  The MRI scan is used to detect cancer in the brain and spinal cord.  A PET scan can check the lymph nodes and other areas of the body for cancer.

If you have breast cancer, your doctor will assign your cancer a classification stage based on the results of all of your tests.  Staging describes the tumor and how it has grown or metastasized.  Staging also includes the axillary lymph nodes because they are the gateway for spreading cancer to the rest of the body.  Staging is helpful for treatment planning and recovery prediction. 

There are different systems for staging breast cancer, and you should make sure that you understand the system that your doctor is using.  The most common staging system for breast cancer is from the American Joint Commission on Cancer.  This system uses the Roman numerals I through IV, with a higher number indicating a more serious cancer.  Some of the stages are also divided in to sub-stages labeled A-B.  The stages of breast cancer, according to the American Joint Commission on Cancer are:

Stage 0:  The cancer or pre-cancerous cells are in their original location within normal breast
tissue.  This includes ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS). 
Stage I:  The tumor is smaller than 2 cm. in diameter and has not spread beyond the breast.
Stage IIA:  The tumor is 2 to 5 cm. and has not spread to the axillary lymph nodes or the
tumor is less than 2 cm. and has spread to the axillary lymph nodes.
Stage IIB:  The tumor is greater than 5 cm. and has not spread to the axillary lymph nodes or the
tumor is 2 to 5 cm. and has spread to the axillary lymph nodes.
Stage IIIA:  The tumor is smaller than 5 cm. and has spread to the axillary lymph nodes that are
attached to each other or to other structures, or the tumor is larger than 5 cm. and has spread to the axillary lymph nodes.
Stage IIIB:  The tumor has spread outside of the breast to the skin or chest wall or has spread to
the lymph nodes inside the chest wall along the sternum.
Stage IV:  A tumor of any size that has spread beyond the breast and chest wall, such as to the liver, bone, or lungs.

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Treatment

Your doctor will refer you to a medical and/or surgical oncologist for treatment.  An oncologist is a doctor with special training in cancer and cancer treatments.  Treatment for breast cancer depends on many factors, including the stage of the cancer and the cancer cell type.  Cancer treatments include local treatment, systemic treatment, adjuvant therapy, and neoadjuvant therapy.

Local treatments treat the tumor without affecting the rest of the body.  Local treatments include surgery and radiation therapy.  Surgery removes the cancer cells from the body.  Radiation therapy uses high-energy rays to destroy cancer cells. 
 
Systemic treatments use medications or cancer-fighting drugs to treat cancer.  The medications are swallowed or administered directly into the bloodstream.  Systemic treatments include chemotherapy, hormone therapy, and immunotherapy. 
 
Adjuvant therapy is used for suspected cancer cells that remain in the body after surgery.  In some cases, cancer cells may break away from the main tumor and spread through the bloodstream and start new tumors in other areas.  Adjuvant therapy is used to remove these hidden cells.  Neoadjuvant therapy includes systemic treatments, such as chemotherapy, that are given before surgery to shrink a tumor. 
 
The goals of treatment for Stage 0 though Stage III breast cancers are to treat the cancer and prevent it from spreading.  Stage IV breast cancer is generally not considered curable, and treatments are aimed at preventing symptoms and improving quality of life.  Breast cancer surgery and follow up treatments are very individualized.  Your doctor will discuss which options are best for you, as well as your expected recovery.

Most breast cancer tumors are treated with surgery.  There are several types of surgery for breast cancer.  Some of the most common types of breast cancer surgeries include lumpectomy, partial or segmental mastectomy, simple or total mastectomy, modified radical mastectomy, and radical mastectomy. 
 
A lumpectomy removes only the tumor and some healthy tissue around it.  It is considered a conservation therapy because only the affected area is removed from the breast.  A lumpectomy is typically followed with chemotherapy and/or radiation therapy.  A partial or segmental mastectomy removes the tumor and more of the breast tissue than a lumpectomy does.
 
The entire breast is removed with a simple or total mastectomy.  The lymph nodes under the arm and the muscle tissue beneath the breast are not removed.  A modified radical mastectomy removes the entire breast and some of the lymph nodes under the arm.  A radical mastectomy removes the entire breast, lymph nodes, and chest wall muscles underneath of the breast. 
 
Some further form of treatment usually follows all types of surgery.  This may include radiation therapy, chemotherapy, hormone therapy, or combinations of each.  These treatments may last for several months.

MammoSite® 5-day Targeted Radiation Therapy is an advanced high-dose radiation treatment that may be an alternative to mastectomy for some women.  Traditional radiation methods work to kill cancer cells, but in the process, also destroy some healthy tissue around the targeted area.  Mammosite following lumpectomy is a breast conservation therapy.  It spares as many healthy cells as possible because it directs a high-dose of radiation to only a specific area surrounding the lumpectomy cavity, the area where cancer recurrence is most likely to occur.  Additionally, the duration of treatment time for Mammosite is shorter than other radiation therapies, shortened from several weeks to just five days. 

In some cases, even with treatment, breast cancer can return.  This is termed “recurrent breast cancer.”  Recurrent breast cancer may come back near the original site or in distant organs.  Your doctor can explain your risk of recurrent cancer and possible treatments if it does recur. 
 
There are several options for women who choose to modify the appearance of their breast after breast cancer surgery.  Professionals can help you select special bras containing breast forms.  Breast forms are made of a variety of materials to replicate a natural breast.  Some women may choose to consult a cosmetic surgeon that specializes in breast reconstruction to have surgery to change the appearance of their breast.  Other women may choose to do nothing at all.  Breast modification and reconstruction is an individualized decision.  There is no right or wrong answer.  You should discuss your concerns with your doctor.  Your doctor can provide you with referrals that are appropriate for you.

The experience of cancer and cancer treatments can be an emotional process for people with cancer and their loved ones.  It is important that you receive support.  Some people find comfort in their family, friends, co-workers, and places of worship.  Cancer support groups are another good option.  They can be a good source of information and support from people who understand what you are experiencing.  Ask your doctor for cancer support group locations in your area.

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Prevention

Some types of breast cancer are treatable if detected early.  The American Cancer Society has recommended guidelines for breast cancer screening.  This includes yearly mammograms for women over the age of 40.  They recommend clinical breast exams by a health expert every three years for women in their 20’s and 30’s, and yearly for women over the age of 40.  It can be helpful for women to perform breast self-examinations beginning in their 20’s.  A health care professional can instruct you on how to perform a breast self-examination.  Additionally, instructions for breast self-examination are available from the American Cancer Society.
 
You can also change your lifestyle to reduce the risk factors for breast cancer that may be controlled.  This includes maintaining an appropriate weight, exercising regularly, and not drinking alcohol. 
 
Women with a high risk for breast cancer should talk to their doctor about screening recommendations particular to them.  They may need earlier or additional tests.  Genetic counselors can determine if a woman has certain genes linked to breast cancer.  Some medications may help prevent breast cancer in some women with a high risk.  In rare cases, women with an extremely high risk of breast cancer may have a preventative mastectomy.  This operation removes both breasts before any evidence of cancer is found. 
 
If you have been diagnosed and treated for breast cancer, you will have regular follow-up visits.  It is important that you tell your doctor about any side effects, symptoms, or concerns at these appointments.  Your doctor will monitor you for cancer recurrence.
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Am I at Risk

Risk factors may increase your likelihood of developing breast cancer, although some people that develop breast cancer do not have any risk factors.  People with all of the risk factors may never develop the disease; however, the chance of developing breast cancer increases with the more risk factors you have.  You should tell your doctor about your risk factors and discuss your concerns.
 

Risk factors for breast cancer:
 

_____  Females experience the majority of breast cancers.  Breast cancer can certainly develop
in men, but they account for less than 1% of all cases.
_____  The majority of breast cancer cases and breast cancer related deaths occur in females
over the age of 50, although breast cancer can develop in people younger than age 50. 
_____ Some genetic traits have been linked with the development of breast cancer.  Some families appear to have defective genes that can cause breast cancer and reduce the body’s ability to eliminate abnormal cells.
_____ A family history of breast cancer increases a woman’s risk of having breast cancer.  Women with a mother, sister, or daughter with breast cancer have about double the risk of developing breast cancer.
_____ Women that have had breast cancer have a greater chance of developing a new case of breast cancer in the same or other breast.
_____  Caucasian women are slightly more likely to get breast cancer than women of other races are.  African American women are more likely to die from breast cancer. 
_____ Women that took diethylstilbestrol (DES) during pregnancy to prevent miscarriage have a slightly increased risk of getting breast cancer.
_____  Women with early menstruation, before 12 years old, or late menopause, after age 55, have a higher risk for developing breast cancer.
_____ Women who have never had children or who had children after the age of thirty have a higher risk for developing breast cancer.
_____   Oral contraceptives (birth control pills) increase the risk of developing breast cancer depending on the type of pill and the length of time used.
_____ Hormone Replacement Therapy (HRT) increases the risk of breast cancer.
_____ Consuming more than one or two drinks of alcohol per day increases the risk of breast cancer.
_____  People exposed to radiation or who had chest radiation treatments for other cancers have an increased risk for developing breast cancer.
_____ Researchers suggest a link between obesity and the development of breast cancer, although the results of these studies are not conclusive.

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Complications

Metastases can be a complication of breast cancer.  This means that the cancer has spread from the breast to distant tissues and organs.  Common sites for breast cancer metastases include the lungs, liver, and bones.  The cancer will need to be treated in the distant organs as well as in the breast. 
 
Recurrent breast cancer can occur after treatment.  Recurrent breast cancer may return in the breast, breast area, or in distant organs.  Recurrent breast cancer is treated as appropriate.
The side effects of radiation therapy and chemotherapy can be harsh for some people.  The type of side effects you experience may depend on the type of radiation therapy or chemotherapy that you receive.  Tell your doctor about the side effects you experience.  In some instances, steps can be taken to relieve or reduce the amount of side effects. 
 
Side effects from chemotherapy may include temporary hair loss, nausea, vomiting, diarrhea, loss of appetite, mouth sores, fatigue, changes in menstrual cycle, increased risk of infection, and bruising or bleeding from minor cuts.  Most side effects subside after treatment.  Your hair will grow back, although it may look different.  You may experience permanent changes in your menstrual cycle, including early menopause.  Additionally, some women experience changes in concentration and memory, which may persist for a long time. 
 
Potential side effects of radiation therapy include breast swelling or tenderness, sunburn-like skin changes, and fatigue.  The side effects from radiation may last from six to 12 months.  Some women may experience permanent breast changes.  In some cases, the breasts become firmer and smaller after radiation.
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Advancements

Researchers are continually working on methods to prevent and treat breast cancer.  Genetics are a growing area of study.  Researchers are trying to pinpoint the cause of breast cancer and medications that may prevent cancer growth.  Several new drugs are being studied in clinical trials.
 
New biopsy methods use MRI imaging to reduce the size and number of biopsy incisions.  Breast surgery methods continually strive to reduce the amount of tissue that is removed to retain a more natural looking breast.  Reconstructive surgery after mastectomy has evolved to include safer breast implants and improved surgical methods.
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This information is intended for educational and informational purposes only. It should not be used in place of an individual consultation or examination or replace the advice of your health care professional and should not be relied upon to determine diagnosis or course of treatment.

The iHealthSpot patient education library was written collaboratively by the iHealthSpot editorial team which includes Senior Medical Authors Dr. Mary Car-Blanchard, OTD/OTR/L and Valerie K. Clark, and the following editorial advisors: Steve Meadows, MD, Ernie F. Soto, DDS, Ronald J. Glatzer, MD, Jonathan Rosenberg, MD, Christopher M. Nolte, MD, David Applebaum, MD, Jonathan M. Tarrash, MD, and Paula Soto, RN/BSN. This content complies with the HONcode standard for trustworthy health information. The library commenced development on September 1, 2005 with the latest update/addition on February 16, 2022. For information on iHealthSpot’s other services including medical website design, visit www.iHealthSpot.com.