What Is Breast Cancer

What Is Breast Cancer 2

What Is Breast Cancer 3

What Is Breast Cancer 4

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     Breast cancer

ARTICLE SECTIONS

• Introduction

• Signs and symptoms

• Causes

• Risk factors

• When to seek medical advice

• Screening and diagnosis

• Treatment

• Prevention

• Coping skills

Introduction

Breast cancer is the illness that many women fear most, though they're more likely to die of cardiovascular disease than they are of all forms of cancer combined. Still, breast cancer is second only to lung cancer as a cause of cancer deaths in American women. Although rare, breast cancer can also occur in men — in the United States, more than 200,000 women and around 1,500 men will develop the disease in 2005.

Yet there's more reason for optimism than ever before. In the last 30 years, doctors have made great strides in diagnosing and treating the disease and in reducing breast cancer deaths. In 1975 a diagnosis of breast cancer usually meant radical mastectomy — removal of the entire breast along with underarm lymph nodes and skin and muscles underneath the breast. Today, radical mastectomy is rarely performed. Instead, there are more and better treatment options, and many women are candidates for breast-sparing operations.

Signs and symptoms

Knowing the signs and symptoms of breast cancer may help save your life. When the disease is discovered early, you have more treatment options and a better chance for long-term recovery.

Most breast lumps aren't cancerous. Yet the most common sign of breast cancer for both men and women is a lump or thickening in the breast. Often, the lump is painless. Other signs of breast cancer include:

• A spontaneous clear or bloody discharge from your nipple

• Retraction or indentation of your nipple

• A change in the size or contours of your breast

• Any flattening or indentation of the skin over your breast

• Redness or pitting of the skin over your breast, like the skin of an orange

A number of factors other than breast cancer can cause your breasts to change in size or feel. In addition to the natural changes that occur during pregnancy and your menstrual cycle, other common noncancerous (benign) breast conditions include:

• Fibrocystic changes. This condition can cause your breasts to feel ropy or granular.

Fibrocystic changes are extremely common, occurring in at least half of all women. In most cases the changes are harmless. And they don't mean you're more likely to develop breast cancer.

If your breasts are very lumpy, performing a breast self-exam is more challenging. Becoming familiar with what's normal for you through self-exams will help make detecting any new lumps or changes easier.

• Cysts. These are fluid-filled sacs that frequently occur in the breasts of women ages 35 to 50. Cysts can range from very tiny to about the size of an egg. They can increase in size or become more tender just before your menstrual period, and may disappear completely after it. Cysts are less common in postmenopausal women.

• Fibroadenomas. These are solid, noncancerous tumors that often occur in women during their reproductive years. A fibroadenoma is a firm, smooth, rubbery lump with a well-defined shape. It will move under your skin when touched and is usually painless. Over time, fibroadenomas may grow larger or smaller or even disappear completely.

Although your doctor can usually identify a fibroadenoma during a clinical exam, a small tissue sample is necessary to confirm the diagnosis.

• Infections. Breast infections (mastitis) are common in women who are breast-feeding or who recently have stopped breast-feeding, although you can also develop mastitis when you're not nursing.

Your breast will likely be red, warm, tender and lumpy, and the lymph nodes under your arm may swell. You also feel slightly ill and have a low-grade fever.

• Trauma. Sometimes a blow to your breast or a bruise also can cause a lump.

But this doesn't mean you're more likely to get breast cancer.

• Calcium deposits (microcalcifications).

These tiny deposits of calcium can appear anywhere in your breast and often show up on a mammogram. Most women have one or more areas of microcalcifications of various sizes. They may be caused by secretions from cells, cellular debris, inflammation, trauma or prior radiation.

They're not the result of calcium supplements you take. The majority of calcium deposits are harmless, but a small percentage may be precancerous or cancer. If any appear suspicious, your doctor will likely recommend additional tests and sometimes a biopsy.

If you find a lump or other change in your breast and haven't yet gone through menopause, you may want to wait through one menstrual cycle before seeing your doctor. If the change hasn't gone away after a month, have it evaluated promptly.

Causes

Each of your breasts contains 15 to 20 lobes of glandular tissue, arranged like the petals of a daisy. The lobes are further divided into smaller lobules that produce milk during pregnancy and breast-feeding. Small ducts conduct the milk to a reservoir that lies just beneath your nipple. Supporting this network is a deeper layer of connective tissue called stroma.

The spaces between the lobes and ducts are filled with fat, which makes up about 80 percent to 85 percent of your breast during your reproductive years. Your breasts also contain vessels that transport lymph — a colorless fluid that carries waste products and cells of the immune system — to lymph nodes located primarily under your arm (axillary nodes) but also above your collarbone and in your chest. These nodes are collections of immune system cells that filter harmful bacteria and play a key role in fighting infection.

In breast cancer, some of the cells in your breast begin growing abnormally. These cells divide more rapidly than healthy cells do and may spread through your breast, to the lymph or to other parts of your body (metastasize). The most common type of breast cancer begins in the milk-producing ducts, but cancer may also occur in the lobules or in other breast tissue.

In most cases, it isn't clear what triggers abnormal cell growth in breast tissue, but doctors do know that between 5 percent and 10 percent of breast cancers are inherited. Defects in one of two genes, breast cancer gene 1 (BRCA1) or breast cancer gene 2 (BRCA2), put you at greater risk of developing both breast and ovarian cancer. Inherited mutations in the ataxia-telangiectasia mutation gene, the cell-cycle checkpoint kinase 2 (CHEK-2) gene and the p53 tumor suppressor gene also make it more likely that you'll develop breast cancer.

Yet most genetic mutations related to breast cancer aren't inherited but instead develop during your lifetime. These acquired mutations may result from radiation exposure — women treated with chest radiation therapy in childhood, for instance, have a significantly higher incidence of breast cancer than do women not exposed to radiation.

Mutations may also develop as a result of exposure to cancer-causing chemicals, such as the polycyclic aromatic hydrocarbons found in tobacco and charred red meats.

In the long run, establishing a link between genetic mutations and cancer is just the first step. Now researchers are trying to learn if a relationship exists between genetic makeup and environmental factors that may increase the risk of breast cancer. Although these studies are still preliminary, breast cancer eventually may prove to have a number of causes.

Risk factors

A risk factor is anything that makes it more likely you'll get a particular disease.

Yet all risk factors aren't created equal. Some, such as your age, sex, and family history can't be changed, whereas others, including smoking and a poor diet are personal choices over which you have some control.

But having one or even several risk factors doesn't necessarily mean you'll become sick — most women with breast cancer have no known risk factors other than simply being women. In fact, being female is the single greatest risk factor for breast cancer. Although men can develop the disease, it's 100 times more common in women.

Other factors that may make you more susceptible to breast cancer include:

• Age. Your chances of developing breast cancer increase as you get older. The disease rarely affects women younger than 25 years of age, whereas close to 80 percent of breast cancers occur in women older than age 50. At age 40, you have a one in 252 chance of developing breast cancer. By age 85, your chance is one in eight.

• A personal history of breast cancer. If you've had breast cancer in one breast, you have an increased risk of developing cancer in the other breast.

• Family history. If you have a mother, sister or daughter with breast or ovarian cancer or both, or even a male relative with breast cancer, you have a greater chance of also developing breast cancer.

In general, the more relatives you have with breast cancer who were premenopausal at the time of diagnosis, the higher your own risk. If you have one close relative with the disease, your risk is doubled. If you have two or more relatives, your risk increases even more.

Just because you have a family history of breast cancer doesn't mean it's hereditary, though. Most people with a family history of breast cancer (familial breast cancer risk) haven't inherited a defective gene, such as BRCA1 or BRCA2.

Rather, cancer becomes so common in women who live into their 80s and beyond that random, noninherited breast tumors may appear in more than one member of a single family.

• Genetic predisposition. Between 5 percent and 10 percent of breast cancers are inherited. Defects in one of several genes, especially BRCA1 or BRCA2, put you at greater risk of developing breast, ovarian and colon cancers. Usually these genes help prevent cancer by making proteins that keep cells from growing abnormally. But if they have a mutation, the genes aren't as effective at protecting you from cancer.

• Radiation exposure. If you received radiation treatments to your chest as a child or young adult, you're more likely to develop breast cancer later in life. The younger you were when you received the treatments, the greater your risk.

• Excess weight. The relationship between excess weight and breast cancer is complex. In general, weighing more than is healthy for your age and height increases your risk if you've gained the weight as an adult and especially after menopause. The risk is even greater if you have more body fat in the upper part of your body. Although women usually have more fat in their thighs and buttocks, they tend to gain weight in their abdomens starting in their 30s, which can increase their risks.

• Exposure to estrogen. The longer you're exposed to estrogen, the greater your breast cancer risk. In general, if you have a late menopause (after age 55) or you began menstruating before age 12, you have a slightly higher risk of developing breast cancer. The same is true for women who never had children, or whose first pregnancy occurred when they were age 35 or older.

• Race. Caucasian women are more likely to develop breast cancer than black or Hispanic women are, but black women are more likely to die of the disease because their cancers are found at a more advanced stage. Although some studies show that black women may have more aggressive tumors, it's also likely that the disparity is at least partially due to socioeconomic factors.

Women of all races with incomes below the poverty level are more often diagnosed with late-stage breast cancer and more likely to die of the disease than are women with higher incomes. Low-income women often don't receive the routine medical care that would allow breast cancer to be discovered earlier.

• Hormone therapy. In July 2002, a study sponsored by the National Institutes of Health (NIH) was halted as researchers reported that hormone therapy, once considered standard treatment for menopausal symptoms, actually posed more health risks than benefits.

Among these was a slightly higher risk of breast cancer for women taking the particular combination of hormone therapy — estrogen plus progestin — used in the study. In addition, combination hormone therapy can make malignant tumors harder to detect on mammograms, leading to cancers that are diagnosed at more advanced stages when they're harder to treat. Because combination hormone therapy can result in serious side effects and health risks, work with your doctor to evaluate the options and decide what's best for you.

• Birth control pills. The hormone therapy studies have raised questions about the relationship between birth control pills and breast cancer. Unfortunately, there are no clear answers. A large study of women between the ages of 35 and 64 published in June 2002 in the "New England Journal of Medicine" concluded that current or former use of oral contraceptives didn't increase the risk of breast cancer. For the latest information on the pill and breast cancer, talk to your doctor.

• Smoking. A Mayo Clinic study published in April 2001 found that smoking significantly increases the risk of breast cancer in women with a family history of breast and ovarian cancers. And a 2005 study published in the "International Journal of Cancer" found that exposure to secondhand smoke also increases the risk of breast cancer in premenopausal women. Researchers think that higher estrogen levels combined with cancer-causing agents in tobacco spark the development of breast tumors.

• Exposure to certain carcinogens. Polycyclic aromatic hydrocarbons are chemicals found mainly in cigarette smoke and charred red meat. Studies have shown that exposure to these chemicals can significantly increase your chances of developing breast cancer. Exposure to certain pesticides also may increase your risk, but more research needs to be done to establish a clear link.

• Excessive use of alcohol. Women who consume more than one alcoholic drink a day have about a 20 percent greater risk of breast cancer than do women who don't drink. The National Cancer Institute recommends limiting alcohol intake to no more than one drink daily.

• Precancerous breast changes (atypical hyperplasia, carcinoma in situ). These changes are often discovered only after you have a breast biopsy for another reason, but they can double your risk of developing breast cancer. If you have carcinoma in situ, discuss treatment and monitoring options with your doctor.

Although most breast changes aren't cancerous, it's important to have them evaluated promptly. If a problem exists, you can have it identified and treated as soon as possible. See your doctor if you discover a lump or any of the other warning signs of breast cancer, especially if the changes persist after one menstrual cycle or they change the appearance of your breast. And if you've been treated for breast cancer, report any new signs or symptoms immediately. These include a new lump in your breast or an ache or pain in a bone that doesn't go away after three weeks. In addition, talk to your doctor about developing a breast-screening program, which may vary, depending on your family history and other significant risk factors.

Screening and diagnosis

Screening — looking for evidence of disease before symptoms appear — is the key to finding breast cancer in its early, treatable stages. Depending on your age and risk factors, screening may include breast self-examination, examination by your nurse or doctor (clinical breast exam), mammograms (mammography) or other tests.

Breast self-examination (BSE)

For years, women have been advised to examine their breasts on a monthly basis starting around age 20. The hope was that by becoming proficient at breast self-examination and familiar with the usual appearance and feel of their breasts, women would be able to detect early signs of cancer.

But some studies have shown that teaching women to perform breast self-exams may not accomplish this goal. A large, randomized clinical study in Shanghai, China, for example, concluded that breast self-exams don't actually reduce the number of deaths from breast cancer. In addition, the study found that women who perform regular breast self-exams may be more likely to undergo unnecessary biopsies after finding breast lumps.

In addition, a Canadian task force reviewed all the studies addressing the role of BSE in reducing breast cancer deaths, and found the evidence supporting the effectiveness of BSE to be inadequate. For these and other reasons, the American Cancer Society changed its recommendations on breast self-examination, stating that the procedure should be considered an option, rather than a requirement, for most women.

The new guidelines emphasize breast health awareness instead of a strict series of monthly self-exams. Although the guidelines don't say you shouldn't perform the exams, the importance of self-exams has been replaced by a general need to become more familiar with your breasts. If you'd like to continue performing breast self-exams, ask your doctor to review your technique.

Clinical breast exam

Unless you have a family history of cancer or other factors that place you at high risk, the American Cancer Society recommends having clinical breast exams once every three years until age 40. After that, the American Cancer Society recommends having a yearly clinical exam.

During this exam, your doctor examines your breasts for lumps or other changes. He or she may be able to feel lumps you miss when you examine your own breasts and will also look for enlarged lymph nodes in your armpit (axilla).

Mammogram

A mammogram, which uses a series of X-rays to show images of your breast tissue, is currently the best imaging technique for detecting tumors before you or your doctor can feel them. For that reason, the American Cancer Society has long recommended screening mammography for all women over 40.

Yet mammograms aren't perfect. A certain percentage of breast cancers — sometimes even lumps you can feel — don't show up on X-rays (false-negative result). The rate is higher for women in their 40s. That's because women of this age and younger tend to have denser breasts, making it more difficult to distinguish abnormal from normal tissue.

At other times, mammograms may indicate a problem when none exists (false-positive result). This can lead to unnecessary biopsies, to fear and anxiety, and to increased health care costs. The skill and experience of the radiologist reading the mammogram also have a significant effect on the accuracy of the test results. In spite of these drawbacks, however, most experts agree that all eligible women should be screened.

In May 2003, the American Cancer Society issued updated guidelines on breast cancer screening, strongly reaffirming its recommendation that women 40 and older have annual mammograms. In 2004, the National Cancer Institute issued a report saying that women older than 50 may need mammograms only every other year, but that younger women, beginning at age 40, are likely to benefit from annual exams.

Additional American Cancer Society screening guidelines include the following:

• If you're in your 20s or 30s, have a clinical breast exam every three years, and have one annually if you're 40 or older.

• Know how your breasts normally feel and report any changes to your doctor. Starting in your 20s, breast self-examination is an option.

• If you're at greater risk of breast cancer because of your family history, genetic makeup, past breast cancer or other significant risk factors, talk with your doctor. You may benefit from more frequent exams, earlier mammography or additional tests.

During a mammogram, your breasts are compressed between plastic plates while a radiology technician takes the X-rays. The whole procedure should take less than 30 minutes. You may find mammography somewhat uncomfortable.

If you have too much discomfort, inform the technician. If you have tender breasts, schedule your mammogram for a time after your menstrual period. Avoiding caffeine for two days before the test may help reduce breast tenderness.

Also available at some mammography centers is a soft, single-use, foam pad that can be placed on the surface of the compression plates of the mammography machine, making the test kinder and gentler. The pad doesn't interfere with the image quality of the mammogram.

If possible, try to schedule your mammogram around the same time as your annual clinical exam. That way the radiologist can specifically look at any changes your doctor may discover.

Most important, don't let a lack of health insurance keep you from having regular mammograms. Many state health departments and Planned Parenthood clinics offer low-cost or free screenings.

So does the ENCOREplus program, available through many YWCAs.
Other screening tests

• Computer-aided detection (CAD). In traditional mammography, your X-rays are reviewed by a radiologist, whose skill and experience play a large part in determining the accuracy of the test results. In CAD, a computer scans your mammogram after a radiologist has reviewed it. CAD identifies more suspicious areas on the mammogram, but many of these areas may later prove to be normal. Still, using mammography andCAD together may increase the cancer detection rate.

• Digital mammography. In this procedure, an electronic process is used to collect and display X-ray images on a computer screen. This allows your radiologist to alter contrast and darkness, making it easier to identify subtle differences in tissue. In addition, the images can be transmitted electronically, so women who live in remote areas can have their mammograms read by an expert who is based elsewhere. Because it's not yet known whether digital mammography is more accurate or effective than conventional mammography, the procedure is undergoing further investigation.

• Magnetic resonance imaging (MRI). This technique uses a magnet linked to a computer to take pictures of the interior of your breast. Although not used for routine screening, MRI can reveal tumors that are too small to detect through physical exams or are difficult to see on conventional mammograms. Some centers may use MRI as an additional screening tool for high-risk women who have dense breast tissue on a mammogram. MRI isn't recommended for routine screening because it has a high rate of false-positive results, leading to unnecessary anxiety and biopsies. It's also expensive, not readily available and requires radiology experts who can interpret the images and findings appropriately.

• Ductal lavage. In this procedure, your doctor inserts a tiny, flexible tube (catheter) into the lining of a duct in your breast — the site where most cancers originate — and withdraws a sample of cells. The cells are then examined for precancerous changes that might eventually lead to disease. These changes show up long before tumors can be detected on a mammogram.

But because ductal lavage is a new procedure, many unknowns remain, including the rate of false-negative results, the exact location in the breast of abnormal cells and whether those cells will necessarily lead to cancer. Clinical trials are being conducted to help find the answers to these questions. In the meantime, it isn't recommended as a screening tool for high-risk women. And because it's considered experimental, many insurers don't cover the procedure. If you have an interest in or questions about the procedure, talk to your doctor.

• Breast ultrasound (ultrasonography). Your doctor may use this technique to evaluate an abnormality seen on a mammogram or found during a clinical exam. Ultrasound uses sound waves to form images of structures deep within the body. Because it doesn't use X-rays, ultrasound is a safe diagnostic tool that can help determine whether an area of concern is a cyst or solid tissue. But breast ultrasound isn't used for routine screening because it has a high rate of false-positive results — finding problems where none exist.

• Molecular breast imaging (MBI). This experimental technique tracks the movement of a radioactive isotope that's taken up by breast tissue and especially by tumors. A special camera shows images of your breast and picks up the isotope signals. In preliminary studies, MBI found small tumors that both mammography and ultrasound missed, and because the procedure uses lighter compression, it may be more comfortable than mammography is. On the downside, the MBI takes time — about 40 to 50 minutes as opposed to 15 minutes for a mammogram — and requires that you be injected with a radioactive isotope. It's also not yet clear how any abnormal findings could be biopsied. Studies of MBI are ongoing.

Diagnostic procedures

If you, your doctor or a mammogram detects a lump in your breast, you'll likely have one or more diagnostic procedures to determine if the lump is cancerous, including:

Ultrasound

Often, your doctor will suggest a less invasive procedure, such as ultrasound, before deciding on a biopsy. Ultrasound is a procedure that uses sound waves to create an image of your breast on a computer screen. By analyzing this image, your doctor may be able to tell whether a lump is a cyst or a solid mass. Cysts, which are sacs of fluid, usually aren't cancerous, although you may want to have a painful cyst drained with a needle.

Biopsy

In some cases, your doctor may want to remove a small sample of tissue (biopsy) for analysis in the laboratory. Biopsies can provide important information about an unusual breast change and help determine whether surgery is needed and if so, the type of surgery required. To obtain a tissue sample, your doctor may use one of the following procedures:

• Fine-needle aspiration biopsy. The simplest type of biopsy, this is used for lumps you or your doctor can feel. During the procedure your doctor uses a thin, hollow needle to withdraw cells from the lump. He or she then sends the cells to a lab for analysis. The procedure isn't uncomfortable, takes about 30 minutes and is similar to drawing blood. Another procedure, fine-needle aspiration, is used primarily to remove the fluid from a painful cyst, but it can also help distinguish a cyst from a solid mass.

• Core needle biopsy. During this procedure, a radiologist or surgeon uses a hollow needle to remove tissue samples from a breast lump. As many as 15 samples, each about the size of a grain of rice, may be taken, and a pathologist then analyzes them for malignant cells. The advantage of a core needle biopsy is that it removes tissue, rather than just cells, for analysis. Sometimes your radiologist or surgeon may use ultrasound to help guide the placement of the needle.

• Stereotactic biopsy. This technique is used to sample and evaluate an area of concern that can be seen on a mammogram but that cannot be felt or seen on an ultrasound. During the procedure, a radiologist takes a core needle biopsy, using your mammogram as a guide. Stereotactic biopsy usually takes about an hour and is performed using local anesthesia.

• Wire localization. Your doctor may recommend this technique when a worrisome lump is seen on a mammogram but can't be felt or evaluated with a stereotactic biopsy. Using your mammogram as a guide, a thin wire is placed in your breast and the tip guided to the lump. Wire localization is usually performed right before a surgical biopsy and is a way to guide the surgeon to the area to be removed and tested.

• Surgical biopsy. This remains one of the most accurate methods for determining whether a breast change is cancerous. During this procedure, your surgeon removes all or part of a breast lump. In general, a small lump will be completely removed (excisional biopsy). If the lump is larger, only a sample will be taken (incisional biopsy). The biopsy is generally performed on an outpatient basis in a clinic or hospital.

Estrogen and progesterone receptor tests

If a biopsy reveals malignant cells, your doctor will recommend additional tests — such as estrogen and progesterone receptor tests — on the malignant cells. These tests help determine whether female hormones affect the way the cancer grows. If the cancer cells have receptors for estrogen or progesterone or both, your doctor may recommend treatment with a drug such as tamoxifen, which prevents estrogen from binding to these sites.

Staging tests

Staging tests help determine the size and location of your cancer and whether it has spread. They also help your doctor determine the best treatment for you. Cancer is staged using the numbers 0 through IV.

Stage 0 cancers are also called noninvasive, or in situ (in one place) cancers. Although they don't have the ability to spread to other parts of your body or invade normal breast tissue, it's important to have them removed because they eventually can become invasive cancers. Finding and treating a cancerous lump at this stage offers the best chance for a full recovery.

Stage I to IV cancers are invasive tumors that have the ability to spread to other areas. A stage I cancer is small and well localized and has a very successful treatment rate. But the higher the stage number, the lower the chances of cure. By stage IV, the cancer has spread beyond your breast to other organs, such as your bones, lungs or liver. Although it may not be possible to eliminate the cancer at this stage, its spread may be controlled with radiation, chemotherapy or both.

Genetic testing

The discovery of BRCA1, BRCA2 and other genes that may increase breast cancer risk has raised a number of emotional and legal questions about genetic testing. A simple blood test can help identify defective BRCA genes, but it's not 100 percent accurate and most experts believe that only women at high risk of hereditary breast or ovarian cancers should be referred for testing. If you're one of these women, it's important to know that having a defective BRCA gene doesn't mean you'll get breast cancer. In addition, test results cannot determine how high your risk is, at what age you might develop cancer, how aggressively the cancer might progress or what your risk of death may be.

In general, testing is most beneficial if the results of the test will help you make a decision about how you might best reduce your chance of developing breast cancer. Options range from lifestyle changes and closer screening and therapy with medications such as tamoxifen to extreme measures such as preventive (prophylactic) bilateral mastectomy and removal of your ovaries (oophorectomy). These can be wrenching decisions for any woman to make. Be sure to thoroughly discuss all your options with a genetic counselor, who can explain the risks, benefits and limitations of genetic testing. It can also help to talk to other women who have had to make similar decisions.

Treatment

A diagnosis of breast cancer is one of the most difficult experiences you can face. In addition to coping with a life-threatening illness, you must make complex decisions about treatment. In most cases no one right treatment exists for breast cancer. Instead, you'll want to find the approach that's best for you.

To do that, you'll need to consider many different factors, including the type and stage of your cancer, your age, risk factors, where you are in your life, the size and shape of your breasts, and your feelings about your body.

Before making any decisions, learn as much as you can about the many treatment options that exist. Talk extensively with your health care team. Consider a second opinion from a breast specialist in a breast center or clinic. Don't be afraid to ask questions. In addition, look for breast cancer books, Web sites, and information from organizations such as the American Cancer Society and the Susan G. Komen Breast Cancer Foundation. Talking to other women who have faced the same decision also may help. This may be the most important decision you ever make.

Treatments exist for every type and stage of breast cancer. Most women will have surgery and an additional (adjuvant) therapy such as radiation, chemotherapy or hormone therapy. And several experimental treatments are now offered on a limited basis or are being studied in clinical trials.

Surgery

At one time, the only type of breast cancer surgery was radical mastectomy, which removed the entire breast, along with chest muscles beneath the breast and all the lymph nodes under the arm. Today, this operation is rarely performed. Instead, the majority of women are candidates for breast-saving operations, such as lumpectomy. Less radical mastectomies and mastectomy with reconstruction are also options.

Breast cancer operations include the following:

• Lumpectomy. This operation saves as much of your breast as possible by removing only the lump plus a surrounding area of normal tissue. Many women can have lumpectomy — often followed by radiation therapy — instead of mastectomy, and in most cases survival rates for both operations are the same.

In addition, many more women are satisfied with their appearance after lumpectomy. But lumpectomy may not be an option if a tumor is deep within your breast, or if you have already had radiation therapy, have two or more areas of cancer in the same breast that are far apart, have a connective tissue disease that makes you sensitive to radiation, or are pregnant.

In general, lumpectomy is almost always followed by radiation therapy to destroy any remaining cancer cells. But when very small, noninvasive cancers are involved, some studies question the role and benefits of radiation therapy — especially for older women. These studies haven't shown that lumpectomy plus radiation prolongs a woman's life any better than does lumpectomy alone.

A study in the "New England Journal of Medicine" found that it might be reasonable for some women 70 and older who were taking tamoxifen after a lumpectomy to forgo radiation. In the study of 600 older women, the five-year survival rate for the half treated with tamoxifen and radiation after lumpectomy and the half treated with tamoxifen alone was essentially the same, although breast cancer recurred more often in the women who took only tamoxifen.

Ultimately, a number of factors will influence your decision regarding radiation after lumpectomy, including the type of cancer you have and how far it has spread, other health conditions you may have, the side effects of radiation, whether you're a candidate for treatment with tamoxifen or aromatase inhibitors, and your own concerns and personal preferences. For some women, the risks of radiation therapy may seem too daunting. For others, fear of cancer recurrence may outweigh all other factors. That's why it's important to review with a radiation oncologist your options and the risks and benefits of treatment.

• Partial or segmental mastectomy. Also considered a breast-sparing operation, partial mastectomy involves removing the tumor as well as some of the breast tissue around the tumor and the lining of the chest muscles that lie beneath it. Some lymph nodes under your arm also may be removed. In almost all cases, you'll have a course of radiation therapy following your operation.

• Simple mastectomy. During a simple mastectomy, your surgeon removes all your breast tissue — the lobules, ducts, fatty tissue and a strip of skin with the nipple and areola. Depending on the results of the operation and follow-up tests, you may also need further treatment with radiation to the chest wall, chemotherapy or hormone therapy.

• Modified radical mastectomy. In this procedure, a surgeon removes your entire breast and some underarm (axillary) lymph nodes, but leaves your chest muscles intact. This makes breast reconstruction less complicated. But serious arm swelling (lymphedema) — a common complication of mastectomy — is more likely to occur in modified radical mastectomy than in simple mastectomy with sentinel node biopsy. Your lymph nodes will be tested to see if the cancer has spread. Depending on those results, you may need further treatment.

• Sentinel lymph node biopsy. Breast cancer first spreads to the lymph nodes under the arm. That's why all women with invasive cancer need to have these nodes examined. If your surgeon doesn't plan to do this, be sure you understand the reason why. Until recently, surgeons would remove as many lymph nodes as possible. But this greatly increased the risk of numbness, recurrent infections and serious swelling of the arm. That's why a procedure has been developed that focuses on finding the sentinel nodes — the first nodes to receive the drainage from breast tumors and therefore the first to develop cancer. If a sentinel node is removed, examined and found to be healthy, the chance of finding cancer in any of the remaining nodes is very small and no other nodes need to be removed. This spares many women the need for a more extensive operation and greatly decreases the risk of complications.

Reconstructive surgery

Most women who undergo mastectomy are able to choose whether to have breast reconstruction. This is a very personal decision, and there's no right or wrong choice. You may find, however, that you have feelings you didn't expect about your breasts. It's important to understand these feelings before making any decision.

If you would like reconstruction, but aren't a candidate for the procedure, you'll need to find a way to come to terms with your disappointment. It may be extremely helpful to talk to other women who have experienced the same situation.

If reconstruction is an option, your surgeon will refer you to a plastic surgeon. He or she can describe the procedures to you and show you photos of women who have had different types of reconstruction. Your options include reconstruction with a synthetic breast implant or reconstruction using your own tissue to rebuild your breast. These operations can be performed at the time of your mastectomy or at a later date.

• Reconstruction with implants. Using artificial materials to reconstruct your breast involves implanting a silicone shell filled with either silicone gel or salt water (saline). If you don't have enough muscle and skin to cover an implant, your doctor may use a tissue expander. This is an empty implant shell that inflates as fluid is injected. It's placed under your skin and muscle, and your doctor gradually fills it with fluid — usually over a period of several months.

When your muscle and skin have stretched enough, the expander is removed and replaced with a permanent implant. Recovery may take several weeks. In general, an implant makes your breast firmer than a normal breast. Implants may cause pain, swelling, bruising, tenderness or infection. And they do age over time, requiring replacement. There is also a long-term possibility of rupture, deflation, contracture, hardening and shifting.

• Reconstruction with a tissue flap. Known as a transverse rectus abdominis myocutaneous (TRAM) flap, this surgery reconstructs your breast using tissue, including fat and muscle, from your abdomen. Sometimes your surgeon may also use tissue from your back or buttocks. Because the procedure is fairly complicated, recovery may take six to eight weeks. You may also need future adjustments to the breast. Complications include the risk of infection and tissue death. If you have little body fat, this type of reconstruction may not be an option for you. On the other hand, a breast reconstructed from your own tissue doesn't seem to interfere with the detection of tumors. It is also permanent and has the look and feel of a normal breast.

• Deep inferior epigastric perforator (DIEP) reconstruction. In this procedure, fat tissue from your abdomen is used to create a natural-looking breast. But because your abdominal muscles are left intact, you're less likely to experience complications than you are with traditional breast reconstruction. You may also have less pain, and your healing time may be reduced. Active women, in particular, tend to opt for this procedure because it maintains the abdominal wall muscles.

• Reconstruction of your nipple and areola. After initial surgery with either tissue transfer or an implant, you may have further surgery to make a nipple and areola. Using tissue from elsewhere in your body, your surgeon first creates a small mound to resemble a nipple. He or she may then tattoo the skin around the nipple to create an areola. Your surgeon may also take a skin graft from elsewhere on your body, place it around the reconstructed nipple to slightly raise the skin and then tattoo the skin graft.

Radiation therapy

Radiation therapy uses high-energy X-rays to kill cancer cells and shrink tumors. It's administered by a radiation oncologist at a radiation center. In general, radiation is the standard of care following a lumpectomy for both invasive and noninvasive breast cancer. Oncologists are also likely to recommend radiation following a mastectomy for a large tumor that has spread to more than four lymph nodes in your armpit.

Radiation is usually started three to four weeks after surgery. You'll typically receive treatment five days a week for five to six consecutive weeks. The treatments are painless and are similar to getting an X-ray. Each takes about 30 minutes. The effects are cumulative, however, and you may become quite tired toward the end of the series. Your breast may be pink, puffy and somewhat tender, as if it had been sunburned.

In a small percentage of women, more serious problems may occur, including arm swelling, damage to the lungs, heart or nerves, or a change in the appearance and consistency of breast tissue. Radiation therapy also makes it somewhat more likely that you'll develop another tumor. For these reasons, it's important to learn about the risks and benefits of radiation therapy when deciding between lumpectomy and mastectomy. You may also want to talk to a radiation oncologist about clinical trials investigating shorter courses of radiation.

Chemotherapy

Chemotherapy uses drugs to destroy cancer cells. Your doctor may recommend chemotherapy following surgery to kill any cancer cells that may have spread outside your breast. Treatment often involves receiving two or more drugs in different combinations. These may be administered intravenously, in pill form or both. You may have between four and eight treatments spread over three to six months.

For many women, chemotherapy can feel like another illness. The side effects may include hair loss, nausea, vomiting and fatigue. These occur because chemotherapy affects healthy cells — especially fast-growing cells in your digestive tract, hair and bone marrow — as well as cancerous ones. Not everyone has side effects, however, and there are now better ways to control some of them.
New drugs can help prevent or reduce nausea, for example. Relaxation techniques, including guided imagery, meditation and deep breathing, also may help. In addition, exercise has been shown to be effective in reducing fatigue caused by chemotherapy.

One side effect for which no treatment exists is "chemobrain," the common term for cognitive changes that occur during and after cancer treatment. Women undergoing adjuvant chemotherapy for breast cancer were the first to call attention to this problem. Since then, researchers have found that chemotherapy can affect your cognitive abilities in a number of ways, including:

• Word finding. You might find yourself reaching for the right word in conversation.

• Memory. You might experience short-term memory lapses, such as not remembering where you put your keys or what you were supposed to buy at the store.

• Multitasking. Many jobs require you to manage multiple tasks during the day. Multitasking is important at work as well as at home — for example, talking with your kids and making dinner at the same time. Chemotherapy may affect how well you're able to perform multiple tasks at once.

• Learning. It might take longer to learn new things. For example, you might find you need to read paragraphs over a few times before you really grasp the content.


• Processing speed. It might take you longer to do tasks that were once quick and easy for you.

Up to one-third of people undergoing cancer treatment will experience cognitive impairment, though some studies report that at least half the participants have memory problems. Memory changes often continue for at least a year or two after your treatment and may last longer.

Premature menopause and infertility also are potential side effects of chemotherapy. The older you are when you begin treatment, the more likely you are to develop these problems. In rare cases, certain chemotherapy medications may lead to cancer of the white blood cells (acute myeloid leukemia) — often years after treatment ends.

Hormone therapy

Hormone therapy is most often used to treat women with advanced (metastatic) breast cancer or as an adjuvant treatment — a therapy that seeks to prevent a recurrence of cancer — for women diagnosed with early-stage estrogen receptor positive cancer.

Estrogen receptor positive cancer means that estrogen or progesterone might encourage the growth of breast cancer cells in your body. Normally, estrogen and progesterone bind to certain sites in your breast and in other parts of your body.

But during this treatment, a hormonal medication binds to these sites instead and prevents estrogen from reaching them. This may help destroy cancer cells that have spread or reduce the chances that your cancer will recur.

Medications that reduce the effect of estrogen in your body include:

• Tamoxifen (Nolvadex). This is a synthetic hormone belonging to a class of drugs known as selective estrogen receptor modulators (SERMs). It's used as a treatment for women with hormone-sensitive metastatic breast cancer, as an adjuvant therapy for women with early-stage estrogen receptor positive breast , and as a preventive agent in high-risk women. You take tamoxifen daily, in pill form, for up to five years. It may reduce the risk of recurrence of breast cancer and is less toxic than most anticancer drugs. But tamoxifen isn't trouble-free.

Women taking tamoxifen may experience menopausal symptoms such as night sweats, hot flashes, and vaginal itch, discharge or dryness. Less common but potentially life-threatening side effects also can occur. These include blood clots in your lungs (pulmonary embolism) and legs (deep vein thrombosis) and endometrial cancer. Older women, especially those with other medical conditions, may be at greater risk of these side effects than are younger women. In addition, some studies have shown that side effects of systemic adjuvant therapies — chemotherapy and tamoxifen — may be more long-term than originally thought.

• Aromatase inhibitors. This class of drugs, which includes anastrozole (Arimidex), letrozole (Femara) and exemestane (Aromasin), blocks the conversion of a hormonal substance (androstenedione) into estrogen. The substance occurs in fat, adrenal gland and ovarian tissues. In a series of clinical trials conducted over several years, the three aromatase inhibitors were tested in various settings. In all cases, women receiving aromatase inhibitors fared better than did those receiving tamoxifen, and the benefits continued even after treatment ended. Women treated with aromatase inhibitors also had a lower incidence of blood clots and endometrial cancer than women taking tamoxifen did.


To date, the primary drawback of aromatase inhibitors is an increased risk of osteoporosis. But although some experts recommend that aromatase inhibitors replace tamoxifen as the primary adjuvant treatment for post-menopausal women with breast cancer promoted by estrogen, others urge caution. The main question seems to be whether women should take tamoxifen first and then switch to an aromatase inhibitor or simply take an aromatase inhibitor from the start. More research will likely be needed to answer these and other questions about adjuvant therapies.

Biological therapy

Sometimes called biological response modifier or immunotherapy, this treatment tries to stimulate your body's immune system to fight cancer. Using substances produced by the body or similar substances made in a laboratory, biological therapy seeks to enhance your body's natural defenses against specific diseases. Many of these therapies are experimental and available only in clinical trials. One medication, trastuzumab (Herceptin), is a monoclonal antibody — a substance produced in a laboratory by mixing cells — that's available for treating certain advanced cases of breast cancer.

Herceptin is effective against tumors that produce excess amounts of a protein called HER-2.

Clinical trials

A number of new approaches to treating cancer are being studied. The emphasis is on methods that can successfully treat women or extend their survival with minimal side effects. Among these are drugs that block the biochemical switches that cause normal cells to turn cancerous. In addition, a procedure known as anti-angiogenesis — which targets the blood vessels that supply nutrients to cancer cells — is also being studied.

Of particular interest to both women and their doctors are methods of removing breast cancer without actually cutting into or removing the breast. Nonsurgical methods being studied include techniques that use heat or cold to kill cancer cells deep within the breast, leaving only minimal scars.

One of the most researched techniques, radiofrequency ablation, uses ultrasound to locate the tumor. Then a metal probe about the size of a toothpick is inserted into the tumor where it creates heat that destroys cancer cells. In early tests, the procedure has proved successful. Still, not all women would be candidates for the procedure if it eventually were approved for widespread use.

Some of these new treatments are available through clinical trials — the standard way new therapies are tested in people. If you have advanced breast cancer and are interested in participating in a clinical trial, talk to your doctor or contact the National Cancer Institute's Cancer Information Service at (800) 422-6237 for more information.

Prevention

Clinical exams and mammography won't prevent breast cancer. But these important procedures can help detect cancer in its earliest stages. The sooner you receive a diagnosis, the more options you have, the more effective your treatment and the better your overall prognosis.

In most cases, doctors don't know what causes breast cancer. The number of tumors associated with a mutation in the breast cancer gene is small — about 10 percent to 15 percent. That's why research is focusing on newer measures you can take that may help reduce your risk. Following are some suggestions to reduce your risk:

• Ask your doctor about aspirin. Taking an aspirin just once a week may help protect against breast cancer. A study published in the "Journal of the American Medical Association" in May 2004 found that women who had had breast cancer and took aspirin once a week for six months or longer were 20 percent less likely to develop breast cancer than were women who didn't take the drug. Women who took a daily aspirin had an even greater reduction in risk. Regular use of ibuprofen (Advil, Motrin, others) also seems to help protect against breast cancer, but not as effectively as aspirin.

These are retrospective studies, however, and other types of studies are needed to determine whether aspirin and other anti-inflammatory drugs are truly beneficial. What's more, aspirin and ibuprofen are effective only against breast cancers that have receptors for the female hormones estrogen and progesterone, which are known to stimulate tumor growth. The drugs may work by reducing estrogen levels in your body and breast tissue. They do this by blocking a hormone-like substance (prostaglandin) that's needed to activate an enzyme (aromatase activity) important in the synthesis of estrogen.

Be sure to talk to your doctor before you start taking aspirin as a preventive measure. When used for long periods of time, aspirin can cause serious side effects including stomach irritation, bleeding and ulcers, bleeding in the intestinal and urinary tracts, and hemorrhagic stroke. In general, you're not a candidate for aspirin therapy if you have a history of ulcers, liver or kidney disease, bleeding disorders, or gastrointestinal bleeding.

• Limit alcohol. A strong link exists between alcohol consumption and breast cancer. As little as 10 grams of alcohol a day — an average drink contains about 15 grams of alcohol — may increase your lifetime risk of breast cancer by 10 percent. The type of alcohol consumed — wine, beer or mixed drinks — seems to make no difference. To help protect against breast cancer, limit the amount of alcohol you drink to less than one drink a day or avoid alcohol completely. Some studies indicate that folic acid might help reduce the risk of breast cancer in women who consume moderate amounts of alcohol.

• Maintain a healthy weight. There's a clear link between obesity — weighing more than is appropriate for your age and height — and breast cancer. This is even more true if you gain the weight later in life, particularly after menopause.

• Discuss long-term hormone therapy with your doctor. The Women's Health Initiative study of 2002 raised concerns about the use of hormone therapy for symptoms of menopause. Among other problems, long-term treatment with estrogen-progestin combinations such as those found in the drug Prempro increased the risk of breast cancer. If you're taking hormone therapy, consider your options with your doctor. You may be able to manage your menopausal symptoms with exercise, dietary changes and nonhormonal therapies that have been shown to provide some relief. If none of these work for you, you may decide that the benefits of short-term therapy outweigh the risks. In that case, your doctor will encourage you to use the lowest dose of hormone therapy for the shortest period of time.

• Stay physically active. The Nurses' Health Study, a long-term study of more than 120,000 female nurses, found that women who exercised for at least one hour a day reduced their breast cancer risk by 18 percent. Those who exercised for 30 minutes every day reduced their risk by 10 percent. Walking was found to be as effective as more vigorous types of exercise. Other studies have shown that women who exercise consistently for at least 10 years of life — whether in adolescence or adulthood — can cut their risk of cancer by a large margin.

In addition, experts now think that young women who routinely exercise even a few hours a week during their teenage years can significantly reduce their risk of breast cancer later in life. Exercise can also help postmenopausal women cut their risk by reducing fat cells, which continue to produce estrogen after menopause. No matter what your age, a good place to start is to aim for at least 30 minutes of exercise on most days. If you haven't been active before, start out slowly and work up gradually. Try to include weight-bearing exercises such as walking, jogging or dancing. These have the added benefit of keeping your bones strong.

• Eat foods high in fiber. Try to increase the amount of fiber you eat to between 20 and 30 grams daily — about twice that in an average American diet. Among its many health benefits, fiber may help reduce the amount of circulating estrogen in your body. Foods high in fiber include fresh fruits and vegetables and whole grains.

• Consider limiting fat in your diet. Results from the Women's Health Initiative low-fat diet study suggest a slight decrease in risk of invasive breast cancer for women who eat a low-fat diet. But the effect is modest at best. However, by reducing the amount of fat in your diet, you may decrease your risk of other diseases, such as diabetes, cardiovascular disease and stroke. And a low-fat diet may protect against breast cancer in another way if it helps you maintain a healthy weight — another factor in breast cancer risk. For a protective benefit, limit fat intake to less than 35 percent of your daily calories and restrict foods high in saturated fat.

• Emphasize olive oil. When it comes to protecting you from cancer, all oils are not created equal. Oleic acid, the main component of olive oil, appears both to suppress the action of the most important oncogene in breast cancer and to increase the effectiveness of the drug Herceptin.

• Eat plenty of fruits and vegetables. Fruits and vegetables contain vitamins, minerals and antioxidants that can help protect you from cancer. The American Cancer Society recommends five or more servings of fruits and vegetables every day. Look for deep green and dark yellow or orange fruits and vegetables, such as Swiss chard, bok choy, spinach, cantaloupe, mango, acorn or butternut squash, and sweet potatoes. Especially emphasize broccoli and brussels sprouts, which contain a chemical called sulforaphane that may hinder the growth of breast cancer cells. Lycopene, a nutrient found in tomatoes and other red fruits and vegetables such as strawberries and red bell peppers, also may be a powerful anticancer chemical.

• Avoid exposure to pesticides. The molecular structure of some pesticides closely resembles that of estrogen. This means they may attach to receptor sites in your body. Although studies have not found a definite link between most pesticides and breast cancer, it is known that women with elevated levels of pesticides in their breast tissue have a greater breast cancer risk.

• Avoid unnecessary antibiotic use. The results of a large-scale study published in the Feb. 18, 2004, issue of the "Journal of the American Medical Association" found a correlation between antibiotic use and breast cancer. The longer antibiotics were used, the greater the risk. Researchers caution, however, that other factors, such as underlying illness or a weakened immune system, rather than antibiotics themselves may account for the elevated cancer risk. At the same time, taking antibiotics when they're not needed can lead to drug-resistant strains of bacteria, a serious and growing problem.

New directions in research

Scientists are investigating a number of potential preventive therapies for breast cancer, including:

• Retinoids. Natural or synthetic forms of vitamin A (retinoids) may have the ability to destroy or inhibit the growth of cancer cells. Unlike other experimental therapies, retinoids may be effective in premenopausal women and in those whose tumors aren't estrogen-positive. Research is ongoing.

• Flaxseed. Phytoestrogens are naturally occurring compounds that lower circulating estrogens in your body.

Flaxseed is particularly high in one phytoestrogen, lignan, which appears to inhibit estrogen production and which may have the ability to stop the growth of breast cancer tumors.

If so, this would be a particularly encouraging development, because flax is a natural food rather than a drug. Flax is also being investigated for its beneficial effects on such conditions as cardiovascular disease and osteoporosis.

http://www.mayoclinic.com/
health/breast-cancer/DS00328