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What is Cancer?
The body is made up of various kinds of cells, which normally divide in an orderly way to produce more cells only when they are needed. Cancer is a group of diseases - more than 100 types - that occur when cells become abnormal and divide without control or order. What is a tumor?
When cells divide when new cells are not needed, too much tissue is formed. This mass of extra tissue, called a tumor, can be benign or malignant. 
 Beginning tumors:
Malignant tumors: Are cancerous Can invade and damage nearby tissues and organs Metastasize - cancer cells can break away from a malignant tumor and enter the bloodstream or lymphatic system to form secondary tumors in other parts of the body
What are the different types of breast cancer? There are several types of breast cancer, including: The most common type begins in the lining of the ducts and is called ductal carcinoma. Another common type, called lobular carcinoma, occurs in the lobules. When breast cancer metastasizes, or spreads outside the breast, cancer cells are often found in the lymph nodes under the arm. If the cancer has reached these nodes, it may mean that cancer cells have spread to other parts of the body.
Types of breast cancer, in alphabetical order, are: | Adenocarcinoma | | Ductal carcinoma in situ (DCIS) | | Infiltrating (or invasive) ductal carcinoma (IDC) | | Infiltrating (or invasive) lobular carcinoma (ILC) | | Inflammatory breast cancer | | Lobular carcinoma in situ (LCIS) (also called lobular neoplasia) | | Medullary carcinoma | | Mucinous carcinoma | | Paget's disease of the nipple | | Phyllodes tumor (also spelled phylloides) | | Tubular carcinoma | | Risk Factors for Breast Cancer |
Any woman may develop breast cancer. However, the following risk factors may increase the likelihood of developing the disease: Risk factors that cannot be changed: - Gender:Breast cancer occurs nearly 100 times more often in women than in men.
- Aging: A majority of cases occur after age 50.
- Personal history of breast cancer
- Previous breast irradiation
- Family history and genetic factors. Having a close relative, such as a mother or sister, with breast cancer increases the risk.
- Beginning breast disease. Previous breast biopsy in which the tissue showed atypical hyperplasia
- Menstrual periods that began early in life
- Menopause began later in life
| Lifestyle-related risk factors: - Smoking
- Not having children
- Not breastfeeding
- Oral contraceptives
- Obesity and a high-fat diet
- Physical inactivity
- Alcohol
- Estrogen replacement therapy
- Induced abortion
- Obesity after menopause
| Environmental risk factors: - Exposure to pesticides, or other chemicals, is currently being examined as a possible risk factor.
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Although there are some women who are at higher risk, the fact is all women are at risk for breast cancer. That's why it is so important to follow the three-step plan for breast health. Early detection of problems provides the greatest possibility of successful treatment. Some people with one or more risk factors never develop a disease, such as cancer, while others develop cancer and have no known risk factors. Different diseases, including cancers, have different risk-factor lists. When reading about risk factors for breast cancer, keep in mind that the word "risk" is used in different ways: Lifetime risk refers to the probability that a person, over the course of his or her lifetime, will be diagnosed or die from cancer. Over her lifetime, a woman in the United States has a 1 in 8 risk of developing breast cancer, and a 1 in 28 risk of dying from breast cancer. Relative risk is a measure of the strength of the relationship between risk factors and cancer. With respect to breast cancer, it compares the risk of developing breast cancer in women who have a certain trait or exposure to women who do not have the trait or exposure. For example, women who have a family history of breast cancer are about 100 percent more likely to develop breast cancer than women who do not have a family history. Signs and Symptoms of Breast Cancer
The following are the most common symptoms of breast cancer. However, each individual may experience symptoms differently. Early breast cancer usually does not cause pain and may cause no symptoms at all. And, approximately 10 percent of breast cancer patients have no pain or lumps, or other indications of a problem with their breasts. As the cancer grows, however, it can cause changes that women and men should watch for, such as: A lump or thickening (a mass, swelling, skin irritation, or distortion) in or near the breast or in the underarm area A change in the size or shape of the breast A change in the color or feel of the skin of the breast, areola, or nipple (dimpled, puckered, or scaly) Nipple discharge, erosion, inversion, or tenderness
A woman (or man) should consult a physician when any of these changes are noticed.
Diagnostic Procedures for Breast Cancer It is important to remember that a lump or other changes in the breast, or an abnormal area on a mammogram, may be caused by cancer or by other, less serious problems. To determine the cause of any signs or symptoms, your physician will perform a careful physical exam that includes: Personal and family medical history Current overall health status One or more of these breast exams:
| Palpation | carefully feeling the lump and the tissue around it - its size, its texture, and whether
it moves easily. Benign lumps often feel different from cancerous ones.
| | Diagnostic mammography | x-ray procedure of the breast. | | Ultrasonography | high-frequency sound waves, not heard by humans. The sound waves enter the
breast and bounce back. The pattern of their echoes produces a picture called a
sonogram, which is displayed on a screen. This exam is often used along with mammography.
| Nipple discharge examination
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Based on these exams, your physician may decide that no further tests are needed and no treatment is necessary. In such cases, your physician may want to check you regularly to watch for any changes.Often, however, the physician must remove fluid or tissue from the breast to be sent to the laboratory for diagnosis.
This procedure is called biopsy, and there are several types:
| Image-guided biopsies | those aided by ultrasound or other imaging technique
| | Fine needle aspiration | a very fine needle is guided into the suspicious area and a small sample of the tissue is removed. | | Core needle biopsy | a larger needle is guided into the lump to remove a small cylinder of tissue.
| | Surgical biopsy | a surgeon removes part or all of a lump or suspicious area, which is followed by a pathological examination of the tissue to check for cancer cells. |
Stages of Breast Cancer
When breast cancer is diagnosed, tests will be done to find out if the cancer has spread from the breast to other parts of the body. This is called staging, and is an important step toward planning a treatment program. What are the different stages of breast cancer? As defined by the National Cancer Institute, stages of breast cancer are:
Stage 0 - Carcinoma in situ
They are early cancers and account for about 15 to 20 percent of all breast cancers cases.
Patients with this condition have a 25 percent chance of developing invasive breast cancer in either breast in the next 25 years.
There are two types of breast cancer in situ: |
Stage I
Cancer is no larger than 2 centimeters (about 1 inch) and has not spread outside the breast. |
Stage II
Any of the following may be present: Cancer is no larger than 2 centimeters but has spread to the lymph nodes under the arm (the axillary lymph nodes). Cancer is between 2 and 5 centimeters (from 1 to 2 inches), and may or may not have spread to the lymph nodes under the arm. Cancer is larger than 5 centimeters (larger than 2 inches), but has not spread to the lymph nodes under the arm.
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Stage III
Stage IIIA is defined by either of the following: Cancer is smaller than 5 centimeters and has spread to the lymph nodes under the arm, and the lymph nodes are attached to each other or to other structures. Cancer is larger than 5 centimeters and has spread to the lymph nodes under the arm.
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Stage IIIB is defined by either of the following:
Cancer has spread to tissues near the breast (skin or chest wall, including the ribs and the muscles in the chest). Cancer has spread to lymph nodes inside the chest wall along the breast bone.
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Stage IV
This stage is defined by either of the following:
The cancer has spread to other organs of the body, most often the bones, lungs, liver, or brain. The tumor has spread locally to the skin and lymph nodes inside the neck, near the collarbone.
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Inflamatory breast cancer
This is a rare type of cancer in which the breast looks as if it is inflamed because of its red appearance and warmth. Skin may show signs of ridges and wheals or it may have a pitted appearance. Recurrent
In this stage, the cancer has come back (recurred) after treatment. It may come back in the breast, in the soft tissues of the chest (the chest wall), or in another part of the body. Surgery in Breast Cancer Treatment Surgery to remove as much of the cancer as possible is the primary treatment for breast cancer. Today, women have many surgical options and choices.
The type of surgery performed depends upon: the size and location of the breast lump or tumor the type and stage of the breast cancer (If the cancer has spread within the breast or has spread outside of the breast to the lymph nodes, or to other parts of the body.) the size of the breast the woman's preference
There are several types of breast surgery. Your physician can explain the benefits and risks of each type, in addition to answering any questions or concerns you may prior to surgery. Questions to ask your physician before surgery: Which type of surgery do you recommend for me? Why? Where will the incision be located and how much of the breast tissue will be removed? Will any lymph nodes be removed? Will I be able to have breast reconstruction if I have a mastectomy? Do you recommend breast reconstruction at the same time of the mastectomy surgery or at a later date? Will additional treatment such as radiation or chemotherapy be required following surgery? What type of follow up care is needed? How long will it be before I resume my normal activities?
Types of breast cancer surgery | Breast conserving surgery: There are two types of breast conservation (tissue-sparing) surgery. These include a lumpectomy and a partial (segmental) mastectomy. A lumpectomy is the removal of the breast cancer and a portion of normal tissue around the breast cancer lump. The surgeon may also remove some of the lymph nodes under the arm to determine if the cancer has spread. The bean-shaped lymph nodes under the arm (also called the axillary lymph glands) drain the lymphatic vessels from the upper arms, the majority of the breast, the neck, and the underarm  regions. Often breast cancer spreads to these lymph nodes, thereby entering the lymphatic system and allowing the cancer to spread to other parts of the body. Radiation therapy is often administered, following a lumpectomy, to destroy cancer cells that may not have been removed during the lumpectomy procedure. A partial (segmental) mastectomy involves the removal of the breast cancer and a larger portion of the normal breast tissue around the breast cancer. The surgeon may also remove the lining over the chest muscles below the tumor and some of the lymph nodes under the arm. The bean-shaped lymph nodes under the arm (also called the axillary lymph glands) drain the lymphatic vessels from the upper arms, the majority of the breast, the neck, and the underarm regions. Often breast cancer spreads to these lymph nodes, thereby entering the lymphatic system allowing the cancer to spread to other parts of the body. Radiation therapy may also be administered, following a partial mastectomy, to destroy cancer cells that may not have been removed during the partial mastectomy procedure. | | Mastectomy, as a non-breast-conserving procedure: If a woman does not choose a breast-conserving surgery, she may choose a mastectomy (removal of the breast). The physician may recommend a mastectomy under the following circumstances (among others):
If the cancer has spread to other parts of the breast tissue or has spread to the lymph nodes under the arm
If the breast is very small and a lumpectomy would require removing additional breast tissue, resulting in a very deformed breast There are three types of mastectomy. Your physician can explain the benefits and risks of each type: During a total (or simple) mastectomy, the surgeon removes the entire breast (including the nipple, the areola, and most of the overlying skin) and may also remove some of the lymph nodes under the arm, also called the axillary lymph glands. The bean-shaped lymph nodes under the arm drain the lymphatic vessels from the upper arms, the majority of the breast, the neck, and the underarm regions. Often breast cancer spreads to these lymph nodes, thereby entering the lymphatic system allowing the cancer to spread to other parts of the body. During a modified radical mastectomy, the surgeon removes the entire breast (including the nipple, the areola, and the overlying skin), some of the lymph nodes under the arm (also called the axillary lymph glands), and the lining over the chest muscles. In some cases, part of the chest wall muscles is also removed.  "During a radical mastectomy, the surgeon removes the entire breast (including the nipple, the areola, and the overlying skin), the lymph nodes under the arm, also called the axillary lymph glands, and the chest muscles. For many years, this was the standard operation. However, today, a radical mastectomy is rarely performed and is generally only recommended when the breast cancer has spread to the chest muscles.
| | Radiation Therapy in Breast Cancer Treatment What is radiation therapy?
Radiation therapy is a process that precisely sends high levels of radiation directly to the cancer cells. The process may be accomplished by external beam radiation - sending the radiation through the skin (an x-ray-like process), or by the temporary implantation of radioactive seeds into the cancerous tissue. Radiation done after surgery, can kill small areas of cancer that may not be seen during surgery. Radiation may also be done prior to surgery to shrink the tumor, or as a palliative measure to relieve symptoms such as pain. A radiation oncologist will plan your radiation treatment based on your medical history, physical exam, pathology and laboratory reports, and previous mammograms and surgeries. Your chest area will be marked with ink that must stay on your skin for the course of your treatments. These markings assure that the radiation will be given in the exact area. Side effects of radiation therapy:
Possible side effects that may occur during or following radiation include: Fatigue - especially during the later weeks of treatment. Skin problems in the treated area, including soreness, itching, peeling, and/or redness. Toward the end of treatment, the skin may become moist and weepy. Decreased sensation in the breast tissue.
In most cases, the effects of radiation on the skin are temporary and the skin involved in the treated area will heal after the completion of the treatments. Oncologists carefully monitor the intensity and length of each treatment, and the area being treated. In addition, you will have regular physical exams during the course of your treatments. |
Chemotherapy in Breast Cancer Treatment What is chemotherapy?
Chemotherapy is the use of anti-cancer drugs to treat cancerous cells. Chemotherapy reaches all part of the body, not just the cancer cells. The oncologist will recommend a treatment plan for each individual. Specific treatment will be based on: your overall health and medical history your age and whether you are menstruating the type and stage of the cancer your tolerance for specific medications and procedures expectations for the course of the disease your opinion or preference
The oncologist will also determine how long and how often you will have chemotherapy treatments. Chemotherapy can be administered intravenously (in the vein) or by pill, and is usually a combination of drugs. Chemotherapy treatments are often given in cycles; a treatment for a period of time, followed by a recovery period, then another treatment. Chemotherapy may be given in a variety of settings including your home, a hospital outpatient facility, a physician's office or clinic, or in a hospital. |
Other Treatments for Breast Cancer There are several other different types of treatment for breast cancer, for which we will provide a brief overview. These include: Hormone therapy
Hormone therapy is used to prevent the growth, spread, and recurrence of breast cancer. The female hormone estrogen can increase the growth of breast cancer cells in some women. A drug, such as tamoxifen, blocks the effects of estrogen on the growth of malignant cells in breast tissue. However, tamoxifen does not stop the production of estrogen. Hormone therapy may be considered for women whose breast cancers test positive for estrogen or progesterone receptors. A special form of hormone therapy is oophorectomy, surgery to remove the ovaries in women who have not gone through menopause, is a means of stopping the production of estrogen. Adjuvant therapy
Adjuvant therapy is therapy given after primary therapy - usually surgery to remove the cancer - to reduce the chance of the cancer spreading or recurring. The adjuvant therapy may be radiation, chemotherapy, or hormone therapy.
Bone marrow transplant / autologous stem cell therapy
High doses of chemotherapy or radiation are sometimes used to kill cancer cells, also killing healthy blood-forming stem cells. To combat this, stem cells taken earlier from the patient's bone marrow, or separated from the blood, are later returned to the patient to help restore the body's ability to fight infection. |
Study of Tamoxifen and Raloxifene (STAR) The Study of Tamoxifen and Raloxifene, or STAR, is a clinical trial that began at an estimated 400 sites across the United States and Canada early in 1999. Participants in STAR include approximately 22,000 postmenopausal women who are at increased risk for breast cancer. They have received a drug that could reduce their chances of developing breast cancer. STAR builds upon the success of the Breast Cancer Prevention Trial (BCPT), which showed that high-risk women taking the drug tamoxifen for an average of four years had a 49 percent reduced chance of developing breast cancer. STAR will determine whether raloxifene (Evista?), a drug similar to tamoxifen, is also effective in reducing the chance of developing breast cancer in women who have not had the disease, and whether the drug has benefits over tamoxifen, such as fewer side effects. Raloxifene was approved by the FDA as an osteoporosis prevention drug for postmenopausal women. Women chosen to participate in STAR are age 35 or older, are postmenopausal, and have an increased risk of breast cancer as determined by their: age, family history of breast cancer, personal medical history, age at first menstrual period, and age at first live birth. They have been randomly assigned to receive either tamoxifen daily or raloxifene daily for five years. They will receive close follow-up examinations, including mammograms, physical examinations, and gynecologic examinations, on a regular basis for at least 7 years. The National Surgical Adjuvant Breast and Bowel Project (NSABP), which runs the trial, selected the 193 main institutions to participate in STAR, including sites in 48 states, six Canadian provinces, the District of Columbia, and Puerto Rico. These 193 institutions have formed networks with other local physicians, creating an estimated 400 active centers participating in the trial.
Breast Cancer Prevention Trial (BCPT): Tamoxifen as Prevention Therapy for Breast Cancer
In Spring 1998, the National Cancer Institute announced positive results from the Breast Cancer Prevention Trial (BCPT), a clinical trial that studied tamoxifen as a prevention therapy for those at high risk for breast cancer. The BCPT, part of the National Surgical Adjuvant Breast and Bowel Project (NSABP), began in April 1992 to determine whether the non-steroidal anti-estrogen tamoxifen could reduce the incidence of breast cancer in women who were at high risk for development of the disease. Only women who were at increased risk for developing breast cancer participated in the study. They were chosen based on their breast cancer risk as determined by a computer calculation that included specific factors. By September 1997, more than 13,000 women had participated in the study. Data showed the results of tamoxifen treatment to be "highly significant" with a 45 percent reduction in the number of invasive breast cancers seen across all age groups. The data were then turned over to the Endpoint Review, Safety Monitoring, and Advisory Committee for review of toxicity, adverse side effects, and effectiveness of tamoxifen. This independent committee (whose members are not affiliated with either the NSABP or the BCPT) concluded that the overall benefits of treatment with tamoxifen outweighed the overall risks. Tamoxifen is one of the most widely prescribed cancer drugs in the world, and has been the focus of research on its actions, benefits, and risks for more than 25 years. The success of its use as preventive therapy for breast cancer is exciting news for both patients and the medical community. Physicians and researchers caution, however, that, as positive as the BCPT results are, tamoxifen therapy may not be appropriate for all women who are at increased risk for breast cancer. Before tamoxifen is prescribed, a woman and her physician should take into consideration her age, personal history, and family history. She and her physician should also weigh the benefits and risks of tamoxifen. Having an understanding of the protocols used in the BCPT will also help in making the decision on whether to take tamoxifen as preventive therapy. The use of tamoxifen is reportedly associated with some infrequent, but potentially life-threatening side effects. Endometrial cancer, pulmonary embolism, and deep vein thrombosis were noted in the BCPT as conditions that may be caused or adversely affected by tamoxifen. |
