Breast Cancer

Breast cancer is the most common cancer among women. Signs of breast cancer may include a lump in the breast, a change in breast shape, dimpling of the skin, fluid coming from the nipple, or a red scaly patch of skin. In those with distant spread of the disease, there may be bone pain, swollen lymph nodes, shortness of breath, or yellow skin.

After skin cancer, breast cancer is the most common cancer diagnosed in women in the United States. Breast cancer can occur in both men and women, but it's far more common in women.

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Symptoms
Signs and symptoms of breast cancer may include:
• A breast lump or thickening that feels different from the surrounding tissue
• Change in the size, shape or appearance of a breast
• Changes to the skin over the breast, such as dimpling
• A newly inverted nipple
• Peeling, scaling, crusting or flaking of the pigmented area of skin surrounding the nipple (areola) or breast skin
• Redness or pitting of the skin over your breast, like the skin of an orange

Causes

Doctors know that breast cancer occurs when some breast cells begin to grow abnormally. These cells divide more rapidly than healthy cells do and continue to accumulate, forming a lump or mass. Cells may spread (metastasize) through your breast to your lymph nodes or to other parts of your body.

Breast cancer most often begins with cells in the milk-producing ducts (invasive ductal carcinoma). Breast cancer may also begin in the glandular tissue called lobules (invasive lobular carcinoma) or in other cells or tissue within the breast.
Researchers have identified hormonal, lifestyle and environmental factors that may increase your risk of breast cancer. But it's not clear why some people who have no risk factors develop cancer, yet other people with risk factors never do. It's likely that breast cancer is caused by a complex interaction of your genetic makeup and your environment.

Risk factors
Age and gender: If you are a woman and you’re getting older, you may be at risk of developing breast cancer. The risk begins to climb after age 40 and is highest for women in their 70s.
Family history: Having a close blood relative with breast cancer increases your risk of developing the disease. A woman’s breast cancer risk is almost double if she has a mom, sister, or daughter with breast cancer and about triple if she has two or more first-degree relatives with breast cancer.
A breast cancer gene mutation: Up to 10% of all breast cancers are thought to be inherited, and many of these cases are due to defects in one or more genes, especially the BRCA1 or BRCA2 genes. (Scientists are studying several other gene mutations as well.) In the U.S., BRCA1 and BRCA2 mutations are more common in Jewish women of Eastern European descent. Having these defective genes doesn’t mean you will get breast cancer, but the risk is greater: A woman’s lifetime risk of breast cancer with a BRCA1 gene mutation, for example, may be more like 55% to 65% compared to the average 12%.
Breast changes and conditions: Women with dense breasts or with a personal history of breast lumps, a previous breast cancer, or certain non-cancerous breast conditions are at greater risk of developing breast cancer than women who do not have these conditions.
Race/ethnicity: White women are slightly more likely to develop breast cancer than Asian, Hispanic, and African American women. But African American women are more likely to develop more aggressive breast cancer at a younger age and both African American and Hispanic women are more likely to die from breast cancer than white women.
Hormones: Women with early menstrual periods (starting before age 12) and late menopause (after age 55) are at greater risk of getting breast cancer. Scientists think their longer exposure to the female hormone estrogen may be a factor, because estrogen stimulates growth of the cells of the breast. Likewise, use of hormone therapy after menopause appears to boost the risk of breast cancer. Oral birth control pills have been linked to a small increase in breast cancer risk compared with women who never used hormonal contraception. But that risk is temporary: More than 10 years after stopping the pill, a woman’s breast cancer risk returns to average.
Weight: Women who are overweight or obese after menopause are more likely to get breast cancer. The exact reason why isn’t clear, but it may be due to higher levels of estrogen produced by fat cells after menopause. Being overweight also boosts blood levels of insulin, which may affect breast cancer risk.
Alcohol consumption: Studies suggest women who drink two or more alcoholic beverages a day are 1 1/2 times more likely than non-drinkers to develop breast cancer. The risk rises with greater alcohol intake, and alcohol is known to increase the risk of other cancers too. For that reason, the American Cancer Society (ACS) recommends that women stick to one drink a day–or less.
Radiation exposure: A woman’s risk of developing breast cancer may be higher than normal if she had chest radiation for another disease as a child or young adult.
Pregnancy history: Having no children or having a first child after age 30 may increase your risk of breast cancer.
DES exposure: Women who were given the now-banned drug diethylstilbestrol to prevent miscarriage decades ago face a slightly increased risk of breast cancer, as do their daughters.

Breast cancer prevention
While no one can tell you how to prevent breast cancer with any sort of guarantee, there’s evidence to suggest that certain healthy lifestyle changes can lower your breast cancer risk.
• Limit your alcohol intake. The more you drink, the higher your risk of breast cancer.
• Watch your weight. Being overweight or obese boosts your breast cancer risk.
• Exercise. Women who work out regularly have a lower risk of breast cancer than less active women.
• Consider breastfeeding your baby. Women who breastfeed have a lower risk of breast cancer than moms who do not breastfeed their children.
• Reduce your hormone intake. Hormone therapy users are at higher risk for breast cancer. If you’re taking hormones to relieve menopausal symptoms, talk to your doctor about taking the lowest dose that works for you for the shortest time.

Types of breast cancer
You and your doctor need to know the type of breast cancer you have to get the best outcome. Your treatment will depend on where your cancer started, whether it has invaded other breast tissue or spread to other parts of your body, and whether hormones like estrogen or progesterone fuel its growth, among other factors.
Most breast cancers are carcinomas, or cancers that start in cells lining the organs or tissues. “In situ” breast cancers haven’t spread to surrounding tissue, which makes them more treatable, while “invasive” breast cancers have invaded surrounding tissue. “Metastatic” breast cancer means it has spread to other parts of your body, such as the lungs, bones, liver, or brain. And “recurrent” breast cancer means breast cancer has returned.

Ductal carcinoma in situ (DCIS)
This highly treatable pre-cancer (sometimes called “stage 0” breast cancer) starts in a milk duct. It’s the most common type of non-invasive breast cancer, meaning the cells are abnormal but haven’t spread to the surrounding tissue. Over time, DCIS may progress to invasive breast cancer.

Invasive ductal carcinoma (IDC)
This is the most common breast cancer, accounting for 80% of all invasive breast cancer diagnoses. Also called “infiltrating ductal carcinoma,” IDC starts in a milk duct, breaks through the duct wall, and invades the surrounding breast tissue. It can spread to other parts of the body as well. There are also several subtypes of IDC, which are categorized based on features of the tumors that form.

Invasive lobular carcinoma (ILC)
This type of breast cancer begins in the milk-producing glands, called lobules. Also known as “infiltrating lobular carcinoma,” ILC can spread beyond the lobules into surrounding breast tissue and metastasize to other parts of the body. It accounts for about 10% of invasive breast cancers.

Lobular carcinoma in situ (LCIS)
LCIS, also called lobular neoplasia, starts in the milk-producing lobules. Technically, it’s not breast cancer (even though it has carcinoma in its name), but rather a collection of abnormal cells. People with LCIS are more likely to develop breast cancer in the future.

Inflammatory breast cancer (IBC)
This rare, aggressive type of breast cancer causes redness and swelling of the breast. The affected breast can feel warm, heavy, and tender. The skin may become hard or ridged like an orange rind. See a doctor right away if you have these symptoms. Inflammatory breast cancer tends to strike five years earlier, on average, than other types of breast cancer, and it might not show up on a mammogram. African American women are at greater risk for IBC than white women.

Paget disease of the breast (or the nipple)
This rare cancer affects the skin of the nipple and the darker circle of skin, called the areola, surrounding it. People with Paget disease may notice the nipple and areola becoming scaly, red, or itchy. They may also notice yellow or bloody discharge coming from the nipple. Most people who have this condition also have one or more tumors (either DCIS or invasive cancer) in the same breast.

Metaplastic breast cancer
This rare, invasive breast cancer begins in a milk duct and forms large tumors. It may contain a mix of cells that look different than typical breast cancers and can be more difficult to diagnose.

Angiosarcoma of the breast
This quickly growing cancer is rare. It is usually a complication of a prior radiation treatment of the breast.

Diagnosing breast cancer
Tests and procedures used to diagnose breast cancer include:
Breast exam: Your doctor will check both of your breasts and lymph nodes in your armpit, feeling for any lumps or other abnormalities.
Mammogram: A mammogram is an X-ray of the breast. Mammograms are commonly used to screen for breast cancer. If an abnormality is detected on a screening mammogram, your doctor may recommend a diagnostic mammogram to further evaluate that abnormality.
Breast ultrasound: Ultrasound uses sound waves to produce images of structures deep within the body. Ultrasound may be used to determine whether a new breast lump is a solid mass or a fluid-filled cyst.
Removing a sample of breast cells for testing (biopsy) : A biopsy is the only definitive way to make a diagnosis of breast cancer. During a biopsy, your doctor uses a specialized needle device guided by X-ray or another imaging test to extract a core of tissue from the suspicious area. Often, a small metal marker is left at the site within your breast so the area can be easily identified on future imaging tests.
Biopsy samples are sent to a laboratory for analysis where experts determine whether the cells are cancerous. A biopsy sample is also analyzed to determine the type of cells involved 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 options.
Breast magnetic resonance imaging (MRI) : An MRI machine uses a magnet and radio waves to create pictures of the interior of your breast. Before a breast MRI, you receive an injection of dye. Unlike other types of imaging tests, an MRI doesn't use radiation to create the images.

Treatment
Your doctor determines your breast cancer treatment options based on your type of breast cancer, its stage and grade, size, and whether the cancer cells are sensitive to hormones. Your doctor also considers your overall health and your own preferences.
Most women undergo surgery for breast cancer and also receive additional treatment before or after surgery, such as chemotherapy, hormone therapy or radiation.
There are many options for breast cancer treatment, and you may feel overwhelmed as you make complex decisions about your treatment. Consider seeking a second opinion from a breast specialist in a breast center or clinic. Talk to other women who have faced the same decision.

Radiation therapy
Radiation therapy uses high-powered beams of energy, such as X-rays and protons, to kill cancer cells. Radiation therapy is typically done using a large machine that aims the energy beams at your body (external beam radiation). But radiation can also be done by placing radioactive material inside your body (brachytherapy).
External beam radiation of the whole breast is commonly used after a lumpectomy. Breast brachytherapy may be an option after a lumpectomy if you have a low risk of cancer recurrence.
Doctors may also recommend radiation therapy to the chest wall after a mastectomy for larger breast cancers or cancers that have spread to the lymph nodes.
Breast cancer radiation can last from three days to six weeks, depending on the treatment. A doctor who uses radiation to treat cancer (radiation oncologist) determines which treatment is best for you based on your situation, your cancer type and the location of your tumor.
Side effects of radiation therapy include fatigue and a red, sunburn-like rash where the radiation is aimed. Breast tissue may also appear swollen or more firm. Rarely, more-serious problems may occur, such as damage to the heart or lungs or, very rarely, second cancers in the treated area.

Chemotherapy
Chemotherapy uses drugs to destroy fast-growing cells, such as cancer cells. If your cancer has a high risk of returning or spreading to another part of your body, your doctor may recommend chemotherapy after surgery to decrease the chance that the cancer will recur.
Chemotherapy is sometimes given before surgery in women with larger breast tumors. The goal is to shrink a tumor to a size that makes it easier to remove with surgery.
Chemotherapy is also used in women whose cancer has already spread to other parts of the body. Chemotherapy may be recommended to try to control the cancer and decrease any symptoms the cancer is causing.
Chemotherapy side effects depend on the drugs you receive. Common side effects include hair loss, nausea, vomiting, fatigue and an increased risk of developing an infection. Rare side effects can include premature menopause, infertility (if premenopausal), damage to the heart and kidneys, nerve damage, and, very rarely, blood cell cancer.

Breast cancer surgery
• Removing the breast cancer (lumpectomy).During a lumpectomy, which may be referred to as breast-conserving surgery or wide local excision, the surgeon removes the tumor and a small margin of surrounding healthy tissue. A lumpectomy may be recommended for removing smaller tumors. Some people with larger tumors may undergo chemotherapy before surgery to shrink a tumor and make it possible to remove completely with a lumpectomy procedure.
• Removing the entire breast (mastectomy). A mastectomy is an operation to remove all of your breast tissue. Most mastectomy procedures remove all of the breast tissue — the lobules, ducts, fatty tissue and some skin, including the nipple and areola (total or simple mastectomy). Newer surgical techniques may be an option in selected cases in order to improve the appearance of the breast. Skin-sparing mastectomy and nipple-sparing mastectomy are increasingly common operations for breast cancer.
• Removing a limited number of lymph nodes (sentinel node biopsy). To determine whether cancer has spread to your lymph nodes, your surgeon will discuss with you the role of removing the lymph nodes that are the first to receive the lymph drainage from your tumor. If no cancer is found in those lymph nodes, the chance of finding cancer in any of the remaining lymph nodes is small and no other nodes need to be removed.
• Removing several lymph nodes (axillary lymph node dissection). If cancer is found in the sentinel lymph nodes, your surgeon will discuss with you the role of removing 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 have a very increased risk of cancer in the other breast because of a genetic predisposition or strong family history. Most women with breast cancer in one breast will never develop cancer in the other breast. Discuss your breast cancer risk with your doctor, along with the benefits and risks of this procedure.
Complications of breast cancer surgery depend on the procedures you choose. Breast cancer surgery carries a risk of pain, bleeding, infection and arm swelling (lymphedema).
You may choose to have breast reconstruction after surgery. Discuss your options and preferences with your surgeon.
Consider a referral to a plastic surgeon before your breast cancer surgery. Your options may include reconstruction with a breast implant (silicone or water) or reconstruction using your own tissue. These operations can be performed at the time of your mastectomy or at a later date.

Hormone therapy
Hormone therapy — perhaps more properly termed hormone-blocking therapy — is often used to treat breast cancers that are sensitive to hormones. Doctors sometimes refer to these cancers as estrogen receptor positive (ER positive) and progesterone receptor positive (PR positive) cancers.
Hormone therapy can be used before or after surgery or other treatments to decrease the chance of your cancer returning. If the cancer has already spread, hormone therapy may shrink and control it.
Treatments that can be used in hormone therapy include:
• Medications that block hormones from attaching to cancer cells (selective estrogen receptor modulators)
• Medications that stop the body from making estrogen after menopause (aromatase inhibitors)
• Surgery or medications to stop hormone production in the ovaries
Hormone therapy side effects depend on your specific treatment, but may include hot flashes, night sweats and vaginal dryness. More serious side effects include a risk of bone thinning and blood clots.

Targeted therapy drugs
Targeted drug treatments attack specific abnormalities within cancer cells. As an example, several targeted therapy drugs focus on a protein that some breast cancer cells overproduce called human epidermal growth factor receptor 2 (HER2). The protein helps breast cancer cells grow and survive. By targeting cells that make too much HER2, the drugs can damage cancer cells while sparing healthy cells.
Targeted therapy drugs that focus on other abnormalities within cancer cells are available. And targeted therapy is an active area of cancer research.
Your cancer cells may be tested to see whether you might benefit from targeted therapy drugs. Some medications are used after surgery to reduce the risk that the cancer will return. Others are used in cases of advanced breast cancer to slow the growth of the tumor.

Supportive (palliative) care
Palliative care is specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness. Palliative care specialists work with you, your family and your other doctors to provide an extra layer of support that complements your ongoing care. Palliative care can be used while undergoing other aggressive treatments, such as surgery, chemotherapy or radiation therapy.
When palliative care is used along with all of the other appropriate treatments, people with cancer may feel better and live longer.
Palliative care is provided by a team of doctors, nurses and other specially trained professionals. Palliative care teams aim to improve the quality of life for people with cancer and their families. This form of care is offered alongside curative or other treatments you may be receiving.

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