BREAST CANCER

Breast Cancer is  Cancer that forms in tissues of the breast.

 The most common type of breast cancer

1.     ductal carcinoma, which begins in the lining of the milk ducts (thin tubes that carry milk from the lobules of the breast to the nipple).

2.     Another type of breast cancer is lobular carcinoma, which begins in the lobules (milk glands) of the breast.

3.     Invasive breast cancer is breast cancer that has spread from where it began in the breast ducts or lobules to surrounding normal tissue. Breast cancer occurs in both men and women, although male breast cancer is rare

Risk factors you cannot change

§  Gender: Breast cancer is much more common in women than in men.

§  Age: risk goes up with age.

§  Genetic risk factors: Inherited changes (mutations) in certain genes like BRCA1 and BRCA2 can increase the risk.

§  Family history: Breast cancer risk is higher among women whose close blood relatives have this disease.

§  Personal history of breast cancer: A woman with cancer in one breast has a greater chance of getting another breast cancer (this is different from a return of the first cancer).

§  Race: Overall, white women are slightly more likely to get breast cancer than African-American women. African-American women, though, are more likely to die of breast cancer.

§  Dense breast tissue: Dense breast tissue means there is more gland tissue and less fatty tissue. Women with denser breast tissue have a higher risk of breast cancer.

§  Certain benign (not cancer) breast problems: Women who have certain benign breast changes may have an increased risk of breast cancer. Some of these are more closely linked to breast cancer risk than others. For more details about these, see our document Non-cancerous Breast Conditions.

§  Lobular carcinoma in situ: In this condition, cells that look like cancer cells are in the milk-making glands (lobules), but do not grow through the wall of the lobules and cannot spread to other parts of the body. It is not a true cancer or pre-cancer, but having LCIS increases a woman's risk of getting cancer in either breast later.

§  Menstrual periods: Women who began having periods early (before age 12) or who went through menopause (stopped having periods) after the age of 55 have a slightly increased risk of breast cancer.

§  Breast radiation early in life: Women who have had radiation treatment to the chest area (as treatment for another cancer) as a child or young adult have a greatly increased risk of breast cancer.

§  Treatment with DES: Women who were given the drug DES (diethylstilbestrol) during pregnancy have a slightly increased risk of getting breast cancer.

Breast cancer risk and lifestyle choices

§  Not having children or having them later in life: Women who have not had children, or who had their first child after age 30, have a slightly higher risk of breast cancer. Being pregnant many times or pregnant when younger reduces breast cancer risk.

§  Certain kinds of birth control: Studies have found that women who are using birth control pills or an injectable form of birth control called depot-medroxyprogesterone acetate (DMPA or Depo-Provera) have a slightly greater risk of breast cancer than women who have never used them. This risk seems to go back to normal over time once the pills are stopped.

§  Using hormone therapy after menopause: Taking estrogen and progesterone after menopause (sometimes called combined hormone therapy) increases the risk of getting breast cancer. This risk seems to go back to normal over time once the hormones are stopped.

§  Not breastfeeding: Some studies have shown that breastfeeding slightly lowers breast cancer risk, especially if breastfeeding lasts 1½ to 2 years.

§  Alcohol: The use of alcohol is clearly linked to an increased risk of getting breast cancer. Even as little as one drink a day can increase risk.

§  Being overweight or obese: Being overweight or obese after menopause (or because of weight gain that took place as an adult) is linked to a higher risk of breast cancer.

                    Signs and symptoms of breast cancer

A sign is something that can be observed and recognized by a doctor or healthcare professional (for example, a rash). A symptom is something that only the person experiencing it can feel and know (for example, pain or tiredness). The signs and symptoms of breast cancer can also be caused by other health conditions. It is important to have any unusual symptoms checked by a doctor.The most common symptom of breast cancer is a new lump or mass. A painless, hard mass that has irregular edges is more likely to be cancerous, but breast cancers can be tender, soft, or rounded. They can even be painful. For this reason, it is important to have any new breast mass or lump or breast change checked by a health care professional experienced in diagnosing breast diseases.

Other possible symptoms of breast cancer include:

§  Swelling of all or part of a breast (even if no distinct lump is felt)

§  Skin irritation or dimpling

§  Breast or nipple pain

§  Nipple retraction (turning inward)

§  Redness, scaliness, or thickening of the nipple or breast skin

§  Nipple discharge (other than breast milk)

Sometimes a breast cancer can spread to lymph nodes under the arm or around the collar bone and cause a lump or swelling there, even before the original tumor in the breast tissue is large enough to be felt. Swollen lymph nodes should also be reported to your doctor.

Although any of these symptoms can be caused by things other than breast cancer, if you have them, they should be reported to your doctor so that he or she can find the cause.

The treatment of recurrent cancer and metastatic cancer

Depends on how the cancer was first treated and the characteristics of the cancer mentioned above, Descriptions of the most common treatment options for breast cancer are listed below.  
Surgery
Surgery is the removal of the tumor and surrounding tissue during an operation. Surgery is also used to examine the nearby underarm or axillary lymph nodes. A surgical oncologist is a doctor who specializes in treating cancer with surgery. Generally, the smaller the tumor, the more surgical options a patient has.

The types of surgery include the following:

·         A lumpectomy is the removal of the tumor and a small, cancer-free margin of normal tissue around the tumor. Most of the breast remains. For both DCIS and invasive cancer, radiation therapy to the remaining breast tissue is generally recommended after surgery. A lumpectomy may also be called breast-conserving surgery, a partial mastectomy, quadrantectomy, or a segmental mastectomy.

·         A mastectomy is the surgical removal of the entire breast. There are several types of mastectomies. Talk with your doctor about whether the skin can be preserved, called a skin-sparing mastectomy, or the skin and the nipple, called a total skin-sparing mastectomy.

Lymph node removal and analysis

Cancer cells can be found in the axillary lymph nodes in some cancers; this information is used to determine treatment and prognosis. It is important to find out whether any of the lymph nodes near the breast contain cancer.

Sentinel lymph node biopsy. The sentinel lymph node biopsy procedure allows for the removal of one to a few lymph nodes, avoiding the removal of multiple lymph nodes in an axillary lymph node dissection (see below) procedure for patients whose sentinel lymph nodes are free of cancer. The smaller lymph node procedure helps patients lower the risk of swelling of the arm called lymphedema and decreases the risk of numbness, as well as arm movement and range-of-motion problems, which are long-lasting issues that can severely affect a person’s quality of life.

In a sentinel lymph node biopsy, the surgeon finds and removes about one to three sentinel lymph nodes from under the arm that receive lymph drainage from the breast. The pathologist then examines these lymph nodes for cancer cells. To find the sentinel lymph node, the surgeon injects a dye and/or a radioactive tracer into the area of the cancer and/or around the nipple. The dye or tracer travels to the lymph nodes, arriving at the sentinel node first. The surgeon can find the node when it turns color if the dye is used or gives off radiation if the tracer is used.

If the sentinel lymph node is cancer-free, research has shown that it is likely that the remaining lymph nodes will also be free of cancer and no further surgery is needed. If the sentinel lymph node shows that there is cancer, then the surgeon may perform an axillary lymph node dissection to remove more lymph nodes to look for cancer, depending on the stage of the cancer, the features of the tumor, and the amount of cancer in the sentinel lymph nodes. It is recommended that patients with signs of cancer in the axillary lymph nodes receive an axillary lymph node dissection, regardless of whether a sentinel lymph node biopsy is done. Find out more about ASCO's recommendations for sentinel lymph node biopsy.

Axillary lymph node dissection. In an axillary lymph node dissection, the surgeon removes many lymph nodes from under the arm, which are then examined by a pathologist for cancer cells. The actual number of lymph nodes removed varies from person to person. Recent research has shown that an axillary lymph node dissection may not be needed for all women with early-stage breast cancer with small amounts of cancer in the sentinel lymph nodes. Women having a lumpectomy and radiation therapy who have a smaller tumor and no more than two sentinel lymph nodes involved with cancer may avoid a full axillary lymph node dissection, which helps reduce the risk of side effects and does not decrease survival. If cancer is found in the sentinel lymph node, whether more surgery is needed to remove additional lymph nodes varies depending on the specific situation.

Most patients with invasive cancer will have either a sentinel lymph node biopsy or an axillary lymph node dissection. A sentinel lymph node biopsy alone may not be done if there is obvious evidence of cancer in the lymph nodes before any surgery. In this situation, a full axillary lymph node dissection is preferred. Normally, the lymph nodes are not evaluated when the cancer is DCIS, since the risk of spread is very low. However, the surgeon may consider a sentinel lymph node biopsy for patients diagnosed with DCIS who choose to have or need a mastectomy. If some invasive cancer is found with DCIS at the time of the mastectomy, which happens occasionally, the lymph nodes will then need to be evaluated. Once the breast tissue has been removed with a mastectomy, it is more difficult to find the sentinel lymph nodes since it is not as obvious where to inject the dye.

Reconstructive (plastic) surgery

Women who have a mastectomy may want to consider breast reconstruction, which is surgery to create a breast using either tissue taken from another part of the body or synthetic implants. Reconstruction is usually performed by a plastic surgeon. A woman may be able to have reconstruction at the same time as the mastectomy, called immediate reconstruction, or at some point in the future, called delayed reconstruction. In addition, reconstruction may be done at the same time as a lumpectomy to improve the look of the breast and to match the breasts, this is called oncoplastic surgery, and many breast surgeons can do this without the help of a plastic surgeon. Surgery on the healthy breast is also often done so both breasts have a similar appearance. Talk with your doctor for more information.

External breast forms (prostheses)

An external breast prosthesis or artificial breast form provides an option for women who plan to delay or not have reconstructive surgery. Breast prostheses can be made to provide a good fit and natural appearance for each woman. 

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. When radiation treatment is given using a probe in the operating room, it is called intra-operative radiation. When radiation is given by placing radioactive sources into the tumor, it is called brachytherapy. Although the research results are encouraging, intra-operative radiation and brachytherapy are not widely used, and treatment is reserved for a small cancer with no evidence that it has spread to the lymph nodes.

A radiation therapy regimen (schedule; see below) usually consists of a specific number of treatments given over a set period of time. Most commonly, radiation therapy is given after a lumpectomy, and following adjuvant chemotherapy if recommended. Radiation therapy is usually given daily for a set number of weeks to get rid of any remaining cancer cells near the tumor site or elsewhere in the breast. This helps lower the risk of recurrence in the breast. In fact, with modern surgery and radiation therapy, recurrence rates in the breast are now be less than 5% in the 10 years after treatment, and survival is often the same with lumpectomy or mastectomy.

Adjuvant radiation therapy is also recommended for some women after a mastectomy, depending on the age of the patient, the size of their tumor, the number of lymph nodes under the arm that contain cancer, the width of normal tissue around the tumor removed by the surgeon, the ER, PR, and HER2 status, and other factors.

Neoadjuvant radiation therapy is radiation therapy given before surgery to shrink a large tumor, which makes it easier to remove, although this approach is not common and is only used when a tumor cannot be removed by surgery.

Radiation therapy causes side effects, including fatigue, swelling of the breast, redness and/or skin discoloration/hyperpigmentation and pain/burning in the skin where the radiation was directed, sometimes with blistering or peeling. Very rarely, a small amount of the lung can be affected by the radiation, causing pneumonitis, a radiation-related swelling of the lung tissue. This risk depends on the size of the area that received radiation therapy. In the past, with older equipment and radiation therapy techniques, women who received treatment for breast cancer on the left side of the body had a small increase in the long-term risk of heart disease. Modern techniques are now able to spare most of the heart from the effects of radiation.

Partial breast irradiation

Partial breast irradiation (PBI) is radiation therapy that is given directly to the tumor area, usually after a lumpectomy, instead of the entire breast, as is usually done with standard radiation therapy. Targeting radiation directly to the tumor area more directly usually shortens the amount of time that patients need to receive radiation therapy. However, only some patients may be able to have PBI. Although early results have been promising, PBI is still being studied. It is the subject of a large, nationwide clinical trial, and the results on the safety and effectiveness compared with standard radiation therapy are not yet ready. This study will help find out which patients are the most likely to benefit from PBI.

PBI can be done with standard external-beam radiation therapy that is focused on the area where tumor was removed and not on the entire breast. PBI may also be performed using brachytherapy. Brachytherapy is the use of plastic catheters or a metal wand placed temporarily in the breast. Breast brachytherapy can involve short treatment times, ranging from one dose to one week, or it can be given as one dose in the operating room immediately after the tumor is removed. These forms of focused radiation are currently used only for patients with a smaller, less-aggressive, and node-negative tumor.

Intensity-modulated radiation therapy

Intensity-modulated radiation therapy (IMRT) is a more advanced way to give external-beam radiation therapy to the breast. The intensity of the radiation directed at the breast is varied to better target the tumor, spreading the radiation more evenly throughout the breast. The use of IMRT lessens the radiation dose and the possible damage to nearby organs, such as the heart and lung, and lower the risks of some immediate side effects, such as peeling of the skin during treatment. This can be especially important for women with medium to large breasts who have a higher risk of side effects, such as peeling and burns, compared with women with smaller breasts. IMRT may also help to lessen the long-term effects on the breast tissue that were common with older radiation techniques such as hardness, swelling, or discoloration.

Even though IMRT has fewer short-term side effects, many insurance providers may not cover IMRT. It is important to check with your health insurance company before any treatment begins to make sure it is covered.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, which work by stopping the cancer cells’ ability to grow and divide. Chemotherapy is prescribed by a medical oncologist, a doctor who specializes in treating cancer with medication.

Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).

Chemotherapy may be given before surgery to shrink a large tumor and reduce the risk of recurrence, called neoadjuvant chemotherapy. It may also be given after surgery to reduce the risk of recurrence, called adjuvant chemotherapy. Chemotherapy is also commonly given if a patient has a metastatic breast cancer recurrence.

A chemotherapy regimen (schedule) consists of a specific treatment schedule of drugs given at repeating intervals for a set period of time. Chemotherapy may be given on many different schedules depending on what worked best in clinical trials for that specific type of regimen. It may be given once a week, once every two weeks (also called dose-dense), once every three weeks.

What can I do to reduce my risk of breast cancer?

Lifestyle changes have been shown in studies to decrease breast cancer risk even in high-risk women.  The following are steps you can take to lower your risk:

·         Limit alcohol. The more alcohol you drink, the greater your risk of developing breast cancer. If you choose to drink alcohol — including beer, wine or liquor — limit yourself to no more than one drink a day.

·         Don't smoke. Accumulating evidence suggests a link between smoking and breast cancer risk, particularly in premenopausal women. In addition, not smoking is one of the best things you can do for your overall health.

·         Control your weight. Being overweight or obese increases the risk of breast cancer. This is especially true if obesity occurs later in life, particularly after menopause.

·         Be physically active. Physical activity can help you maintain a healthy weight, which, in turn, helps prevent breast cancer. For most healthy adults, the Department of Health and Human Services recommends at least 150 minutes a week of moderate aerobic activity or 75 minutes of vigorous aerobic activity weekly, plus strength training at least twice a week.

·         Breast-feed. Breast-feeding may play a role in breast cancer prevention. The longer you breast-feed, the greater the protective effect.

·         Limit dose and duration of hormone therapy. Combination hormone therapy for more than three to five years increases the risk of breast cancer. If you're taking hormone therapy for menopausal symptoms, ask your doctor about other options. You may be able to manage your symptoms with nonhormonal therapies, such as physical activity. If you decide that the benefits of short-term hormone therapy outweigh the risks, use the lowest dose that works for you.

·         Avoid exposure to radiation and environmental pollution.Medical-imaging methods, such as computerized tomography, use high doses of radiation, which have been linked with breast cancer risk. Reduce your exposure by having such tests only when absolutely necessary. While more studies are needed, some research suggests a link between breast cancer and exposure to the chemicals found in some workplaces, gasoline fumes and vehicle exhaust.

Can a healthy diet prevent breast cancer?

Eating a diet rich in fruits and vegetables hasn't been consistently shown to offer protection from breast cancer. In addition, a low-fat diet appears to offer only a slight reduction in the risk of breast cancer.

However, eating a healthy diet may decrease your risk of other types of cancer, as well as diabetes, heart disease and stroke. A healthy diet can also help you maintain a healthy weight — a key factor in breast cancer prevention.