Breast Cancer

Breast cancer occurs when the cells in your breast start growing out of control.

These cells accumulate and form a tumor that can either be felt as a lump or detected on an X-ray.

It is the most common cancer affecting women in the United States after skin cancer. Breast cancer can occur in men too, but is more common among women.

Most breast cancers involve the ducts that carry milk to the nipple, and are called ductal cancers.

Sometimes, cancer may occur in the glands that produce breast milk (lobular cancers). There has been substantial support and research funding for breast cancer awareness, which has helped in screening, diagnosis, and advancements in the treatment of breast cancer.

Morover, breast cancer survival rates have been increasing as the number of deaths decline steadily due to a number of factors such as early detection, a new personalized approach to treatment, and a better understanding of the disease.

There may be several symptoms of breast cancer, but the most noticeable sign is a lump or an area of thickened tissue.

Other signs and symptoms of breast cancer include:

• Blood tinged discharge from the nipple
• Change in the size, shape or appearance of one or both breasts
• A lump or swelling in your armpits
• A newly inverted nipple, which appears sunken into your breast
• Peeling, scaling or flaking of the pigmented area of skin surrounding the nipple (areola) or breast skin
• Redness with dimpling or pitting of the skin over your breast (orange peel appearance)

When to see a doctor

If you notice a lump or any other change in your breast — even if a recent mammogram was normal — make an appointment with your doctor for prompt evaluation.

Although it is not known what exactly causes breast cancer, doctors explain that breast cancer occurs when some of the breast cells start growing uncontrollably. These abnormal cells divide in a rapid manner than healthy cells do, and start accumulating to form a lump or mass. These cells may also spread (metastasize) from your breast to the lymph nodes or other parts of your body.

Most often, breast cancer begins in the cells of the milk-producing ducts (invasive ductal carcinoma). It may also begin in the glandular tissue called lobules (invasive lobular carcinoma) or in other cells or tissue of your breast.

Research has identified that hormonal, lifestyle, and environmental factors play an important role in causing breast cancer. And it is unclear why some people without any risk factors develop cancer, yet other group of people with risk factors never do. It is more likely that breast cancer is a result of a complex interaction between your genetic makeup and your environment.

Inherited breast cancer

It has been estimated that only 5-10 percent of breast cancers are linked to genetic mutations that are passed down through generations of a family. Several inherited mutated genes that increase the chances of developing breast cancer have been identified. The most common are breast cancer gene 1 (BRCA1) and breast cancer gene 2 (BRCA2), both of which can increase your risk of both breast and ovarian cancer significantly.

If you have a family history of breast cancer, your doctor will advise a blood test that identifies specific mutations in BRCA or other genes that are being passed through generations. Your doctor will also refer you to a genetic counselor, who reviews your family health history and discusses the benefits, risks, and limitations of genetic testing with you and provides advice on appropriate genetic testing.

Making a diagnosis of breast cancer is done by several tests.

Women with breast cancer may have appointments with their primary care doctors as well as several other health professionals, including:

• Breast health specialists
• Breast surgeons
• Doctors who specialize in diagnostic tests, such as mammograms (radiologists)
• Specialist doctors treating cancer (oncologists)
• Doctors who treat cancer with radiation (radiation oncologists)
• Genetic counselors
• Plastic surgeons

What you can do to prepare

• Write down symptoms you are experiencing, including those that seem unrelated to the reason for your appointment.
• Write down key personal information, including major stresses or recent life changes.
• Write down family history of cancer. Make a note of your family members who have had cancer, including how they are related to you, the type of cancer, the age at diagnosis, and whether each person survived.
• Make a list of all your regular medications, vitamins or supplements.
• Organize all your records that relate to your cancer diagnosis and treatment in a binder or folder that you can carry to your appointments.
• Ask a family member or friend to accompany you if possible. Sometimes, it can be difficult for you to remember all the information provided during an appointment. Someone who comes along may remember something that you have missed or forgotten.

Write down questions to ask your doctor

Preparing a list of questions will save most of your time to discuss other issues, which are more important. For breast cancer, some basic questions to ask your doctor include:

• What type of breast cancer do I have?
• What is the stage of my cancer?
• Can you explain the pathology report to me?
• Can I have a copy of the report for my records?
• Will I need any more tests?
• What treatment options are available for my cancer?
• What are the benefits and side effects from each treatment option you recommend?
• Will treatment lead to menopause?
• How is each treatment going to affect my daily life?
• Will I be able to continue working?
• Is there any treatment that you recommend over the others?
• How quickly do I need to make a decision about my cancer treatment?
• What is the cost of cancer treatment?
• Does my insurance plan cover the tests and treatment that you have suggested?
• Should I take a second opinion?
• Will my insurance cover it?
• Are there any brochures or other printed material that I can refer?
• What websites or books do you recommend for further reading?
• Are there any clinical trials or newer treatments that I should consider?

What to expect from your doctor

Your doctor may ask you a number of questions. Be ready to answer them so that you will have enough time left to discuss other points you want to know. Your doctor may ask:

• When did you notice your symptoms first?
• Have your symptoms been continuous or occasional?
• How severe are your symptoms?
• Is there anything that seems to improve or worsen your symptoms?

Tests and procedures used to diagnose breast cancer include:

• Breast examination: Your doctor will examine both your breasts and lymph nodes in the armpit and feel for any lumps or other abnormalities.

• Mammogram: A mammogram is an X-ray of the breast. It is used to screen for breast cancer. If a screening mammogram detects an abnormality, your doctor will recommend a diagnostic mammogram for further evaluation of that abnormality.

• Breast ultrasound: Ultrasound uses sound waves to create images of internal structures situated deep within the body. Ultrasound help in differentiating between a solid mass and a fluid-filled cyst. An ultrasound is often performed as a part of the examination of a newly formed lump.

• Removing a sample of breast cells for testing (biopsy): Biopsy samples are obtained and sent to a laboratory for analysis which determines whether the cells are cancerous. A biopsy sample is also examined to determine the type of cells present in the breast cancer, the aggressiveness (grade) of the cancer, and whether the cancer cells have hormone receptors or other receptors that may influence your treatment.

• Breast magnetic resonance imaging (MRI): An MRI machine uses a magnet and radio waves to create images of the inner portion of your breast. A special dye may be injected before a breast MRI scan is taken.

Staging breast cancer

Once the diagnosis of breast cancer is made, determining the extent (stage) of your cancer is done. Your stage of cancer determines your prognosis and the most favorable treatment options. Complete information about your cancer's stage is available only after you undergo breast cancer surgery.

Tests and procedures used in staging breast cancer include:

• Blood tests, such as a complete blood count
• Mammogram of the other breast to look for signs of cancer
• Breast MRI
• Bone scan
• Computerized tomography (CT) scan
• Positron emission tomography (PET) scan

All women will not need all of these tests and procedures. Your doctor will select the suitable tests based on your condition and taking into account the symptoms you may be experiencing.

Breast cancer stages range from 0 to IV. Stage 0 refers to cancer that is noninvasive or confined to the milk ducts. Stage IV breast cancer, also called metastatic breast cancer, indicates that cancer that has spread to other areas of the body.

Your doctor derives your breast cancer treatment plan based on

• the type of your breast cancer,
• its stage and grade,
• size,
• whether the cancer cells are hormone-sensitive.

In addition, your overall health and your preferences are also considered. Most women are advised surgery for breast cancer and also receive additional treatment before or after surgery, such as chemotherapy, hormone therapy or radiation.

There are various options for breast cancer treatment, making a decison about your treatment may be complex. Consider seeking a second opinion from a breast specialist in a breast center or clinic.

You may also discuss with other women who have faced the same decision.

Breast cancer surgery

Surgical procedures performed to treat breast cancer include:

Removing the breast cancer (lumpectomy):

During lumpectomy, which is also called breast-sparing surgery or wide local excision, your surgeon will remove the tumor along with a small margin of surrounding healthy tissue. Lumpectomy is usually done for smaller tumors.

Removing the entire breast (mastectomy):

Mastectomy involves surgical removal of all of your breast tissues — the lobules, ducts, fatty tissue and some skin, including the nipple and areola (simple mastectomy). During a skin-sparing mastectomy, the skin over the breast is left intact to make reconstruction and appearance better. Depending on the location and size of the tumor, sometimes, the nipple may also be spared.

Removing a limited number of lymph nodes (sentinel node biopsy):

To detect whether there has been spread of cancer to your lymph nodes, your surgeon will discuss the role of removing the lymph nodes that are the first to receive the lymph drainage from your tumor. If no cancer cells are found in those lymph nodes, the chance of finding cancer in any of the remaining lymph nodes is less and removal of other nodes is not required.

Removing several lymph nodes (axillary lymph node dissection):

If cancer has been detected in the sentinel node, your surgeon will advise removal of additional lymph nodes in your armpit.

Removing both breasts:

Some women with cancer in one breast may choose to have their other (healthy) breast removed (contralateral prophylactic mastectomy) if they are at a very high risk ofdeveloping cancer in the other breast because of a strong genetic predisposition and family history. Discuss your breast cancer risk with your doctor, along with the advantages and risks of this procedure.

Complications of breast cancer surgery depend on the procedure you choose. As with any surgical procedure, there could be a risk of bleeding and infection.

Some women opt for breast reconstruction after surgery. Discuss the options and your preferences with your surgeon. Consider a referral to a plastic surgeon before undergoing your breast cancer surgery. Your options in breast reconstruction include a breast implant (silicone or water-filled) or reconstruction with your own tissue. Those residing in the UK may be interested in learning about breast reconstruction surgery. Guy Sterne is an experienced cosmetic breast surgeon practicing for 25 years within the National Health Service (NHS). He now runs a private practice that specialises in all types of breast surgery. Visit his website for more information. These reconstructive procedures can be performed at the time of your mastectomy or at a later date.

Radiation therapy

Radiation therapy employs high-powered beams of energy, such as X-rays, to destroy cancer cells. Radiation therapy is typically given through a large machine that targets the energy beams at your body (external beam radiation). Radiation therapy can also be given by placing a radioactive material within your body (brachytherapy). For early stage breast cancer, external beam radiation is commonly used after lumpectomy procedure. Doctors may recommend radiation therapy to the chest wall after mastectomy in larger breast cancers or cancers that have spread to the lymph nodes.

Side effects of radiation therapy are fatigue and a red, sunburn-like rash at the area where the radiation was aimed. Breast tissue may appear swollen or more firm. Rarely, more serious problems such as damage to the heart or lungs or, very rarely, secondary cancers in the treated area may occur.

Chemotherapy

Chemotherapy uses drugs to kill cancer cells, and is recommended in achieving control over the symptoms your cancer is causing. If you have a high risk of your cancer returning or spreading to other parts of your body, your doctor may advise chemotherapy to reduce the chances of recurrence of cancer. This is called adjuvant systemic chemotherapy. Chemotherapy is also given before surgery in women with larger breast tumors. Here, the goal is to shrink the tumor to a size that makes surgical removal easier. Chemotherapy is also indicated when cancer has spread to other parts of the body.

Chemotherapy side effects depend on the drugs you receive. Some common side effects that may occur include hair loss, nausea, vomiting, fatigue, and an increased risk of developing infection. Rare side effects are premature menopause, infertility (if premenopausal), damage to the nerves, heart and kidneys, and very rarely, blood cell cancer.

Hormone therapy

Hormone therapy — properly termed hormone-blocking therapy — is used in the treatment of breast cancers that are sensitive to hormones, which are sometimes referred to as estrogen receptor positive (ER positive) and progesterone receptor positive (PR positive) cancers. Hormone therapy is used after surgery or other treatments to reduce chances of your cancer recurrence. If the cancer has spread to other sites already, hormone therapy helps in shrinking and controlling it.

Treatments that can be used in hormone therapy include:

Medications that block hormones from getting attached to cancer cells:

Selective estrogen receptor modulator (SERM) medications prevent estrogen from binding to the estrogen receptor on the cancer cells, thereby slowing down the tumor growth by killing tumor cells. SERMs include tamoxifen, raloxifene (Evista), and toremifene (Fareston). Possible side effects include hot flashes, night sweats, and vaginal dryness. More severe risks include blood clots, stroke, uterine cancer, and cataracts.

Medications that prevent production of estrogen after menopause:

These medications are called aromatase inhibitors. These drugs act by blocking the functions of an enzyme that converts androgen into estrogen. These drugs are advised only in postmenopausal women. Aromatase inhibitors include anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin). Side effects include hot flashes, night sweats, vaginal dryness, joint and muscle pain, as well as an increased risk of bone thinning (osteoporosis).

A drug that targets estrogen receptors for destruction:

The drug fulvestrant (Faslodex) acts by blocking estrogen receptors on the cancer cells and signaling to the cell to destroy these receptors. Fulvestrant is given in postmenopausal women. Side effects that may occur include nausea, hot flashes, and painful joints.

Surgery or medications to stop production of hormones in the ovaries. In premenopausal women, surgical removal of the ovaries or medications to stop the ovaries from producing estrogen can be an effective hormonal treatment.

Targeted drugs

Targeted drug treatments attack specific abnormalities within cancer cells. Targeted drugs used to treat breast cancer include:

Trastuzumab (Herceptin):

Some types of breast cancers produce excessive amounts of a protein called human growth factor receptor 2 (HER2), which facilitates growth and survival of breast cancer cells. If your breast cancer cells make large amounts of HER2, trastuzumab helps block that protein and causes the death of cancer cells. Side effects may include headaches, diarrhea, and heart damage.

Pertuzumab (Perjeta):

Pertuzumab also targets HER2 and is recommended for use in metastatic breast cancer along with trastuzumab and chemotherapy. This combination of treatments is reserved for women who have not received other drug treatments for their cancer. Side effects of pertuzumab may include diarrhea, hair loss, and heart problems.

Ado-trastuzumab (Kadcyla):

This drug is a combination of trastuzumab with a cell-killing drug. When this combination drug enters the body, the trastuzumab finds the cancer cells as it gets attracted to HER2. Then the cell-killing drug is released into the cancer cells. Ado-trastuzumab is a good option for women with metastatic breast cancer who have already received trastuzumab and chemotherapy.

Lapatinib (Tykerb):

Lapatinib acts against HER2 and is recommended in the treatment of advanced or metastatic breast cancer. Lapatinib can be used along with chemotherapy or hormone therapy. Potential side effects include diarrhea, pain in the hands and feet, nausea, and heart problems.

Bevacizumab (Avastin):

Research suggests that this drug does not extend survival time, although it may slow down the growth of breast cancer. Bevacizumab is no longer approved for use in breast cancer treatment in the United States.

Adoption of certain modifications in your lifestyle helps prevent your risk of breast cancer. Try the following measures:

Ask your doctor about breast cancer screening test:

Discuss with your doctor about the schedule of breast cancer screening exams and tests, which include clinical breast exams and mammograms. Talk to your doctor about the advantages and risks of screening. With this information, you can decide on following the breast cancer screening strategy that is most suitable for you.

Learn to perform breast self-examination and be familiar with your breasts:

Women may note any changes in their breasts by inspecting their breasts during a breast self-exam for breast awareness. If there is a new change, lump or other abnormalities in your breasts, talk to your doctor immediately. Breast awareness cannot prevent breast cancer altogether, but it may help you to recognize the abnormal changes that your breasts may undergo and identify unusual signs and symptoms.

Avoid alcohol or drink in moderation:

Limit the amount of alcohol you drink to less than one drink a day, if you choose to drink.

Exercise regularly:

Aim to exercise daily for at least 30 minutes. If you have not been active since long time, ask your doctor whether you can start exercising.

Limit postmenopausal hormone therapy:

Combination hormone therapy may increase the risk of breast cancer. Talk with your doctor about the benefits and risks of hormone therapy. In women who experience bothersome signs and symptoms during menopause, the increased risk of breast cancer may be acceptable in order to relieve menopause signs and symptoms. However, using the lowest dose of hormone possible for the shortest time period can reduce the risk of breast cancer.

Maintain a healthy weight:

If your weight is healthy, work to maintain it within the normal range. If you are overweight, you need to lose weight. You may ask your doctor about healthy strategies to accomplish this. The best way is to limit the number of calories you eat each day and gradual increase in the amount of exercise.

Choose a healthy diet:

Women who follow a Mediterranean diet supplemented with extra-virgin olive oil and mixed nuts have a reduced risk of breast cancer. The Mediterranean diet is mainly plant-based foods such as fruits and vegetables, whole grains, legumes, and nuts. The Mediterranean diet includes healthy fats such as olive oil, over butter and fish instead of red meat.

Breast cancer risk reduction for women with a high risk

If your doctor has assessed your family history and other factors and determined that you may have an increased risk of breast cancer, options to reduce your risk include:

Preventive medications (chemoprevention):

Estrogen-blocking medications can be helpful in reducing the risk of breast cancer. Examples include tamoxifen and raloxifene (Evista). Aromatase inhibitors have also shown some promise in reducing the risk of breast cancer in women with a high risk. These medications can cause side effects, therefore, doctors reserve these medications for women with very high risk of breast cancer. Discuss the benefits and risks of these medications with your doctor.

Preventive surgery:

Women at a very high risk of breast cancer may sometimes opt surgical removal of their healthy breasts (prophylactic mastectomy). They may also have their healthy ovaries removed (prophylactic oophorectomy) to avoid the risk of both breast cancer and ovarian cancer.

There are no alternative remedies that can cure breast cancer. Complementary and alternative medicine therapies may help in coping with the adverse effects of your treatment when used along with your doctor's advise.

Alternative medicine for fatigue

Most breast cancer survivors have fatigue during and after the treatment that may even continue for several years. When used with your doctor's care, complementary and alternative medicine therapies can relieve fatigue. Talk with your doctor about:

Gentle exercise:

With your doctor's recommendation, start with gentle exercises a few times a week and add more if you feel you are capable. Consider walking, swimming, yoga or tai chi.

Manage stress:

Have control over the stress faced in your daily life. Try using stress-reduction techniques such as muscle relaxation, visualization, and spending time with your family and friends.

Express your feelings:

Enrol yourself in an activity that allows you to write or discuss your emotions, such as writing in a journal, participating in a support group or talking to a counselor.

Lifestyle modifications are necessary in order to cope with breast cancer.

A diagnosis of breast cancer can cause distress, and just when you are trying to cope up with the shock and the fears about your future, you are expected to take important decisions about your treatment.

Every woman has her own way of coping with her diagnosis of breast cancer, but until you find the one that works for you, it might help to:

Learn about your breast cancer:

If you would like to know more about your breast cancer, ask your doctor for information of your cancer — the type, stage, and hormone receptor status. Ask for trustworthy sources that provide updated information on your treatment options. Awareness about your cancer and your treatment options keeps you you more confident while making treatment decisions. Still, some women may not be interested in knowing the details of their cancer. If this is something you feel, inform your doctor about that.

Talk to other breast cancer survivors:

Talking and sharing your feelings with other women with breast cancer may be helpful and encouraging. Contact the American Cancer Society to find support groups in your area and online. You can also find someone to talk about your feelings with. It is good to find a friend or family member who is a good listener, or talk with a clergy member or counselor. Your doctor may also refer you to a counselor or other professional who deals with cancer survivors.

Maintain close relationships with your friends and family:

Your friends and family can provide you a crucial support network required during your cancer treatment. Think well in advance about things you need help with, whether it is having someone to talk in case you are feeling low or preparing meals for you.

Maintain intimacy with your partner:

Generally, women's breasts are often associated with her attractiveness, femininity, and sexuality. With these attitudes, breast cancer can affect your self-image and damage your confidence in intimate relationships. Tell your partner about such insecurities and your feelings.

A breast cancer risk factor is anything that increases your chance of developing breast cancer. But having one or even several breast cancer risk factors does not necessarily mean that you will get breast cancer.

Most women who have develoed breast cancer have had no known risk factors other than simply being women. Factors that are associated with an increased risk of breast cancer include:

Gender:

Women are more likely to develop breast cancer.

Advancing age:

Your risk of breast cancer increases as you get older.

A personal history of breast cancer:

If you have had breast cancer or early non-invasive cancer cell changes in ducts of one breast previously, you have an increased risk of developing the cancer again in the same or your other breast.

A family history of breast cancer:

If any of your first-degree relatives such as your mother, sister or daughter were diagnosed with breast cancer, especially at a younger age, you are at an increased risk of developing breast cancer. But, a majority of people diagnosed with breast cancer have no family history of the disease.

Inherited genes:

Certain gene mutations that increase your risk of breast cancer can be inherited from parents. The most common gene mutations are referred to as BRCA1 and BRCA2. These genes can greatly increase your chance of getting breast cancer and other cancers, but they do not make cancer inevitable.

Radiation exposure:

If you have received radiation treatments to your chest during childhood or as young adult, your risk of breast cancer is greater.

Obesity:

If you have had menopause and are overweight or obese, you are at a higher risk of breast cancer. This is because of the higher amount of estrogen produced after menopause if you are overweight or obese.

Getting menstrual periods (menarche) at a younger age:

Beginning your periods before the age of 12 may increase your risk of breast cancer.

Attaining menopause at an older age:

You are more likely to develop breast cancer if you began menopause at an older age.

Conceiving your first child at an older age:

Women who have their first child after the age of 35 may have an increased risk of breast cancer.

Having never been pregnant:

Women who have never conceived are at a greater risk of breast cancer than women who have had one or more pregnancies.

Postmenopausal hormone therapy:

Women undergoing hormone therapy that combine estrogen and progesterone to treat the symptoms of menopause have an increased risk of breast cancer.

Drinking alcohol:

Alcohol consumption can increase your risk of developing breast cancer.