Breast cancer is the most common cancer in women, other than skin cancer, and the second deadliest cancer in U.S. women; lung cancer is the deadliest. Approximately 207,090 cases of invasive breast cancer will be diagnosed in 2010, according to the American Cancer Society (ACS). Though an estimated 39,840 women will die from breast cancer, there are more than 2.5 million breast cancer survivors in the United States, according to the ACS.
Fortunately, the number of deaths caused by breast cancer has declined significantly in recent years, with the largest decreases in younger women—both Caucasian and African American. These decreases are probably the result of earlier detection and improved treatment.
In 2003, The National Cancer Institute found a significant drop in the rate of hormone-dependent breast cancers among women, the most common breast cancer. In a study published in late 2006, researchers speculated that the drop was directly related to the fact that millions of women stopped taking hormone replacement therapy (HRT) in 2002 after a major government study found the treatment slightly increased a woman’s risk for breast cancer, heart disease and stroke. The researchers suggested that stopping the treatment slowed the growth of very tiny cancers into larger tumors that could be detected because they didn’t have the additional estrogen required to fuel their growth.
Breast cancer is a disease in which malignant (cancerous) cells are found in breast tissues. Each breast has 15 to 20 sections called lobes, which have many smaller sections called lobules. The lobes and lobules are connected by thin tubes called ducts.
One of the most important factors when it comes to breast cancer is whether the cancer is invasive or noninvasive. Noninvasive (in situ) cancers are confined to the ducts or lobules and have not spread to surrounding tissues or other parts of the body. Noninvasive cancers can develop into more serious invasive tumors. Invasive breast cancer has spread outside the milk duct and into the normal tissue inside the breast. Whether a breast cancer is invasive or noninvasive determines treatment and prognosis.
The different kinds of breast cancer that involve the lobes, lobules and/or ducts are:
- Ductal carcinoma in situ (DCIS). Also known as intraductal carcinoma or noninvasive breast cancer, DCIS is confined to the ducts and has not invaded surrounding tissue. As the use of screening mammography has increased in the United States, the frequency of DCIS diagnosis has increased significantly. It is the most common subgroup of noninvasive breast cancer; one out of five cases of breast cancer is DCIS.
- Invasive ductal cancer. Also called infiltrating ductal carcinoma, this type of breast cancer is the most common of all breast cancers. It makes up about 80 percent of all newly diagnosed cases of invasive breast cancer. It is found in the cells of the ducts and is usually a hard lump.
- Invasive lobular carcinoma. This form of breast cancer occurs at the ends of the ducts or in the lobules and accounts for 10 percent of invasive breast cancers.
Less common types of breast cancer:
- Mucinous carcinoma (colloid carcinoma). A rare type of invasive breast cancer, mucinous carcinoma is formed by mucin-producing cancer cells. Prognosis for this type of invasive breast cancer is generally better than for other more common types.
- Medullary carcinoma. This type of breast cancer accounts for 3 to 5 percent of all breast cancers and involves a distinct boundary between tumor tissue and normal tissue. It also differs from other forms of invasive ductal cancers in that it contains large cancer cells and immune system cells throughout the tumor. The prognosis for this type of cancer is generally better than for other invasive forms.
- Tubular carcinoma. Tubular carcinoma is characterized by tubular structures ringed with a single layer of cells. Only 2 percent of all breast cancers fall into this category. The prognosis is usually good.
- Paget’s disease. A rare breast cancer in the ducts beneath the nipple accounting for only 1 percent of cases, invasive Paget’s disease starts with an itchy, eczema-like rash around the nipple. Paget’s disease can be associated with a noninvasive or invasive underlying mass. For noninvasive cases, it is believed that the cells have migrated from the ducts of the nipple to the nipple’s epidermis, though this is still under study.
- Inflammatory carcinoma. This aggressive type of breast cancer accounts for 1 to 3 percent of all cases. Skin over the breast appears acutely inflamed and swollen because skin lymph vessels are blocked by cancer.
- Triple-negative breast cancer. This type of breast cancer, usually invasive ductal carcinoma, has cells that lack receptors for the hormones estrogen andprogesterone, and it does not express a specific protein called HER2, which makes tumors grow quickly. Triple-negative breast cancers tend to occur in younger women and Africa-American women and spread more quickly than most other breast cancer types.
- Metaplastic carcinoma. Also called carcinoma with metaplasia, this is a very rare type of invasive ductal breast cancer. These tumor cells make tissue not normally found in the breast such as bone and even cartilage and are treated like invasive ductal cancer.
- Papillary carcinoma. This type of breast cancer, which can be separated into noninvasive and invasive types, includes cells arranged in small, fingerlike projections. These cancers are more common in older women and make up no more than 1 to 2 percent of all breast cancers.
- Mixed tumors. Mixed breast tumors contain a variety of cell types, such as invasive lobular breast cancer combined with invasive ductal cancer.
- Adenoid cystic carcinoma (adenocystic carcinoma). These breast cancers have both cylinder-like (cystic) and glandular (adenoid) features and make up less than 1 percent of breast cancers. Because they rarely spread to the lymph nodes and distant areas, these tumors usually have a very good prognosis.
- Phyllodes tumor. A very rare form of breast cancer, phyllodes tumor forms in theconnective tissue of the breast, called the stroma. Phyllodes tumors are usuallybenign but may be malignant in rare cases.
- Angiosarcoma. This form of breast cancer begins in cells that line blood vessels or lymph vessels. It rarely forms in the breast, but when it does, it usually forms as a result of previous radiation treatment five to 10 years later.
Your risk of developing invasive breast cancer at some time during your lifetime is a little less than one in eight (about 12 percent). This sounds high, but if you consider the term “lifetime,” it helps put your risk in perspective. It means that one in 233 women in their 30s will be diagnosed with breast cancer; one in 69 in their 40s; one in 36 in their 50s; and one in 27 in their 60s. The “one in eight” applies to women in their 80s and 90s. However, as you can see, your risk for developing breast cancer increases with age. In fact, other than being a woman, age is the single greatest risk factor for breast cancer.
You rrisk is higher if you have:
- A family history of breast cancer, specifically, a first-degree relative who has had it (mother, sister, daughter)
- Biopsy-confirmed atypical hyperplasia, or an overgrowth of abnormal cells that are not cancerous
- A mutation in the BRCA1 or BRCA2 tumor suppressor genes
- A mother, sister or daughter with a BRCA1 or BRCA2 mutation, even if you are yet to be tested yourself
- Had radiation to the chest before the age of 40, particularly if it was given in adolescence
- Li-Fraumeni syndrome, Cowden syndrome, Peutz-Jeghers syndrome, are a carrier of ataxia telangiectasia (AT) gene or have a first-degree relative with one of these syndromes.
- Lobular carcinoma in situ (LCIS), which is not a true cancer, though it may be a marker for later cancer risk. Most experts agree that LCIS does not often become an invasive cancer, but women with LCIS do have an increased risk of developing invasive breast cancer.
- A biopsy-confirmed atypical lobular hyperplasia (ALH), which is a noncancerous breast disease characterized by the growth of abnormal cells. ALH may be discovered when a biopsy is done for a lump or to examine an abnormal area found on the mammogram.
Your risk is somewhat higher if you have:
- Dense breast tissue
- Early menstruation (beginning at 12 or younger)
- Late menopause (age 55 or older)
- Never had children or had your first baby after age 30
- Have used hormone therapy for a long time
Your risk may be higher if you:
- Drink heavily
- Are obese
- Are a gay or bisexual woman. These women have a greater risk of breast cancer than other women not because of their sexual orientation, but because they are less likely to have had children. They also may have more lifestyle-related risk factors for breast cancer than heterosexual women, including obesity and cigarette smoking. If you are a lesbian or bisexual woman, you may want to find a lesbian- and/or bisexual-sensitive health professional and schedule regular physicals that include clinical breast examinations and mammography.
A majority of women will have one or more risk factors for breast cancer. However, most risks are so low that they only partly explain the high frequency of the disease in the population.
While you can’t alter some of your personal risk factors for developing breast cancer, such as age or family history, you can adopt specific lifestyle choices, such as maintaining your ideal body weight and exercising, to reduce your risk of the disease.
Early detection of breast cancer, however, provides the best opportunity for successful treatment and reduces your chances of dying from breast cancer.
There are three main ways to detect abnormalities in your breasts that may be cancerous: breast self-examination, mammograms and regular breast exams by your health care professional. Other imaging studies such as ultrasound and MRI (magnetic resonance imaging) can also help find cancer in the breast.
The American Cancer Society recommends an annual mammogram for all women 40 and older. The United States Preventive Services Task Force (USPSTF), an independent government-appointed panel, modified its recommendations in 2009 to say that women ages 50 to 74 should have a mammogram every other year. The USPSTF does not recommend mammograms for women outside of that range, unless they are at high risk for breast cancer, because false positive screening results could require unnecessary follow-up screenings or treatment.
If you are at high risk for developing breast cancer, the ACS suggests you start getting an MRI and mammogram annually at age 30, unless your health care provider suggests a different age. MRI scans are more sensitive than mammograms at detecting an abnormality in women with dense breasts. The two tests together give health care professionals a better chance of finding breast cancer in its early stages, when it is the most treatable.
HealthyWomen recommends that you ask your health care professional about breast cancer screening recommendations with your personal health history in mind.
Breast self-exam (BSE) is an option for women age 20 and older. Although BSE isn’t specifically recommended for breast cancer screening, many women choose to examine their own breasts regularly, which is a good idea. Research has shown that BSE plays a small role in breast cancer detection compared with finding a breast lump by chance. Overall, the main goal of a BSE is to help a woman become familiar with the look and feel of her breasts so she can report any changes to her health care provider right away. Some women feel very comfortable taking a step-by-step approach to doing a monthly BSE. Other women prefer to examine their breasts in a less systematic way, while they are showering or getting dressed, with an occasional more thorough exam. As long as a woman monitors the look and feel of her breasts regularly, either technique is acceptable.
Women who examine their own breasts should keep in mind that breast changes can occur with pregnancy, aging, menopause, during menstrual cycles or when they are taking birth control pills or other hormones.
Ask your health care professional to show you how to perform a BSE correctly or check the American Cancer Society website (www.cancer.org) for detailed instructions. The procedure for doing BSE is different from previous guidelines. There is now evidence that the right amount of pressure, the pattern of coverage of the breast and the position (lying down is best) increase a woman’s ability to feel abnormalities. You may also want to ask for a brochure to help when you get home. It may take several months for you to become familiar with the routine and to learn what to expect to feel. But with practice, BSE can increase your chances of noticing anything abnormal about your breasts.
If you find a suspicious lump or notice something else abnormal, make an appointment with your health care professional. He or she will perform an exam and will likely have you undergo a mammogram. The majority of breast changes found by women who regularly perform BSEs are not cancerous.
Mammograms and Clinical Breast Exams
A mammogram is a specialized X-ray of your breasts from various angles. Although it doesn’t usually hurt, a mammogram can be uncomfortable or embarrassing. A health care professional moves and flattens (breast compression) your breasts on the X-ray machine so it is in the best position for taking X-ray images. The entire procedure typically takes less than 15 minutes.
The value of mammography is that it can identify potentially cancerous breast abnormalities at an early stage before they can be felt. While mammograms can detect a breast lump up to two years before it can be felt during a physical examination, they can miss up to 20 percent of breast cancers.
A clinical breast exam (CBE) is a manual examination of the breasts by a health care professional to check for any suspicious masses. CBE is a complement to mammograms and an opportunity for you and your health care professional to discuss changes in your breasts, early detection testing and factors in your history that might make you more likely to have breast cancer.
According to the American Cancer Society, all women age 40 and older should have an annual screening mammogram and continue to do so as long as they are in good health. Women in their 20s and 30s should have a clinical breast exam conducted by a health care professional at least once every three years; after age 40, women should have a clinical breast exam every year.
Ultrasound and MRI
If something abnormal is detected in a mammogram, the next step is usually to take additional X-ray views or an ultrasound.
Ultrasound is also used to create visual images of breast tissue. Ultrasonography, or ultrasound, uses high-frequency sound waves. The images it creates can be viewed on a monitor and allows your health care professional to see if a breast lump is a fluid-filled cyst (not cancer) or a solid mass (which may or may not be cancer). Ultrasound may be used with a mammogram, and the images produced are printed and/or stored as video.
Magnetic resonance imaging (MRI) uses magnetic fields to show differences between normal and abnormal tissue. For most women at high risk for breast cancer, screening with both mammograms and MRI should start at age 30 (or an age determined by the woman’s health care professional) and continue for as long as a woman is in good health.
For an MRI scan, you lie in a specially designed structure that houses the magnetic field. Contrast material is injected into your veins, and the MRI image shows the dye coursing through the blood vessels in your breasts.
This test is used to detect cancer, determine the extent of disease, monitor response to therapy and screen women at high risk for breast cancer.
Even after an ultrasound or mammogram, if your health care professional still believes the area is suspicious, he or she may recommend a core-needle biopsy, taking a sample of breast tissue by needle and sending it to a pathologist to determine if it’s cancer. Biopsies can usually be done in your doctor’s office under local anesthesia. Fine needle aspiration is frequently performed. However, the rate of false negatives is very high and most often additional studies, like checking for estrogen or progesterone receptors based on an aspiration, are hard to perform.
If Breast Cancer is Found
If breast cancer is found, more tests will be done to find out the size and extent of the cancer in the breast and to determine whether the cancer has spread from the breast to other parts of the body. This is called staging. To plan treatment, your health care professional needs to know the stage of the disease. The following stages are used for breast cancer staging according to the American Joint Committee on Cancer, seventh edition:
- Stage 0: Carcinoma in situ: About 20 percent of breast cancers are very early cancers, sometimes called ductal carcinoma in situ (DCIS).
- Stage I: The cancer is no larger than two centimeters (about one inch) and cannot be detected outside the breast.
- Stage II A: The cancer is no larger than 2 centimeters but has spread to the lymph nodes under the arm.ORThe tumor is larger than 2 centimeters across and less than 5 centimeters but hasn’t spread to the lymph nodes. The cancer hasn’t spread to distant sites.
- Stage II B: The tumor is larger than 2 centimeters and less than 5 centimeters across and has spread to the lymph nodes under the arm and/or tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy. (Sentinel node biopsy removes a small cluster of lymph nodes called sentinel nodes to which cancer first spreads from a primary tumor.) The cancer hasn’t spread to distant sites.ORThe tumor is larger than 5 centimeters across but does not grow into the chest wall or skin and has not spread to lymph nodes. The cancer hasn’t spread to distant sites.
- Stage IIIA: The tumor is not more than 5 centimeters across (or cannot be found). It has spread to between four and nine lymph nodes under the arm, or it has enlarged the internal mammary lymph nodes. The cancer hasn’t spread to distant sites.ORThe tumor is larger than 5 centimeters across but does not grow into the chest wall or skin. It has spread to between one and nine lymph nodes under the arm or to internal mammary nodes. The cancer hasn’t spread to distant sites.
- Stage IIIB: The tumor has grown into the chest wall or skin, and one of the following applies:
- It has not spread to the lymph nodes.
- It has spread to between one and three lymph nodes under the arm and/or tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.
- It has spread to between four and nine lymph nodes under the arm, or it has enlarged the internal mammary lymph nodes.
- The cancer hasn’t spread to distant sites.
Inflammatory breast cancer is classified as stage IIIB unless it has spread to distant lymph nodes or organs, in which case it is stage IV.�
- Stage IIIC: The tumor is any size (or can’t be found), and one of the following applies:
- Cancer has spread to 10 or more lymph nodes under the arm.
- Cancer has spread to the lymph nodes under the clavicle (collar bone).
- Cancer has spread to the lymph nodes above the clavicle.
- Cancer involves lymph nodes under the arm and has enlarged the internal mammary lymph nodes.
- Cancer has spread to four or more lymph nodes under the arm and tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.
- The cancer hasn’t spread to distant sites.
- Stage IV: The cancer has spread to other organs of the body, most often the bones, soft tissue (skin), lungs, liver or brain.
- Recurrent: Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the breast, in the soft tissues of the chest (the chest wall) or in another part of the body.
The treatment you and your health care professional choose will depend upon many things. Treatment often includes surgical, radiation and medical therapy.
The most common surgical treatment for invasive cancer is lumpectomy with sentinel lymph node biopsy technique described below. Also known as excisional biopsy or wide excision, lumpectomy is a breast-conserving surgical procedure. It has become more common in the last 10 years as a means of treating early stage cancer. In fact, studies show that lumpectomy followed by radiation to the breast is just as effective as mastectomy in treating breast cancer.
During lumpectomy, a surgeon removes just the tumor along with a margin of healthy tissue, leaving the remainder of the breast intact, followed by radiation. Regardless of whether you choose lumpectomy or mastectomy, a dissection or sampling of an axillary lymph node or nodes (a large group of lymph nodes located under the armpit or axilla) should be performed for invasive forms of the disease. A new technique called sentinel lymph node sampling takes one to three lymph nodes from under the arm. These lymph nodes are found by injecting a dye into the breast and looking for the first lymph node that picks up this dye. The surgeon can then remove the smallest number of lymph nodes possible. The idea is that if a lymph node is positive for cancer, it is most likely in the sentinel lymph node.
A mastectomy is another common surgical treatment for invasive cancer, and there are two primary types:
- Simple or total mastectomy: The entire breast is removed, including breast tissue, skin, areola and nipple, but not the chest tissue underneath.
- Modified radical mastectomy: The entire breast is removed along with underarm lymph nodes and sometimes the lining over the chest muscles and, more rarely, part of the chest wall muscle. This may be recommended if your tumor is large or if it is your preference.
In addition to surgery, adjuvant therapy is used to kill any cancer cells that may have spread. In deciding whether adjuvant treatment is necessary, your doctor takes into account the extent (stage) and nature of your disease, general health and other prognostic factors.
The choice of the type of adjuvant therapy depends on many factors, such as: whether the cancer cells contain hormone receptors (estrogen and progesterone); whether there is a protein called HER2, which makes tumors grow more quickly; the grade of tumor; and the size of tumor and lymph nodes. Most women receive some form of adjuvant therapy.
Adjuvant therapy usually begins between two and 12 weeks after surgery. It includes chemotherapy and/or hormone therapy, as well as radiation therapy.
- Chemotherapy involves a combination of anticancer drugs. These drugs are powerful and can have many side effects. Anticancer drugs are given by mouth or by injection into a blood vessel. Either way, the drugs enter the bloodstream and travel throughout the body.Chemotherapy is given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. Most patients receive treatment in an outpatient part of the hospital or at the doctor’s office. Adjuvant chemotherapy usually lasts for three to six months.Hormone therapy deprives cancer cells of the female hormone estrogen, which some breast cancer cells need to grow. For many women, hormone therapy means treatment with the drug tamoxifen; fulvestrant (Faslodex), a drug that works similarly to tamoxifen but eliminates the estrogen receptor instead of blocking it; or an aromatase inhibitor, such as anastrozole (Arimidex), letrozole (Femara) or exemestane (Aromasin). Aromatase inhibitors stop estrogen production in post-menopausal women.Several studies have compared aromatase inhibitors with tamoxifen as adjuvant therapy in post-menopausal women with breast cancer and found that aromatase inhibitors better reduce the risk of cancer recurrence than using tamoxifen by itself for five years. The drug schedules that appear to be the most helpful include the following:
- Tamoxifen for two to three years followed by an aromatase inhibitor to complete five years of total treatment
- Tamoxifen for five years, followed by an aromatase inhibitor for five years
- An aromatase inhibitor for five years
For post-menopausal women with hormone receptor-positive breast cancers, experts recommend using aromatase inhibitors as part of adjuvant therapy. Researchers are now investigating the best way to give these drugs, whether it’s before or after tamoxifen or using them for five years or longer.
Tamoxifen also carries some risks, however, including increased risk of stroke, pulmonary emboli and fatal uterine cancers. Patients should discuss these risks with their health care professionals. In most cases, the benefits of using tamoxifen as a treatment for breast cancer outweigh the risks.
Some premenopausal patients may have surgery to remove their ovaries, which are a woman’s main source of estrogen. Or they may be treated with a medication to reduce ovarian function.
- Radiation therapy should be used in patients having a lumpectomy. It is also sometimes used after a mastectomy for women with large cancer tumors or with four or more positive lymph nodes, or when the margins of the surgical removal show some cancer cells. Such treatment can help destroy breast cancer cells that may have been left behind in the area where the breast was. In women that choose breast conserving surgery and have radiation, there is now a new option that shortens the course of treatment from six or seven weeks to five days. Not everyone is a candidate, but this is being evaluated in a national trial.
Choosing the Right Treatment
So how do you know which treatment to choose? Your health care professional will try to determine your prognosis—the likely outcome after treatment. One indicator most commonly used is lymph node involvement.
Cancer cells commonly spread from the breast to lymph nodes in underarm and chest areas. To determine if and how far breast cancer has spread, and which treatment option may be the best option, a number of lymph nodes are typically removed for biopsy to see if they contain cancer cells.
If cancer is found, the woman is said to be “node positive.” If the lymph nodes are free of cancer, the patient is said to be “node negative.” Women who have multiple positive nodes are more likely than those with negative nodes to have a systemic recurrence. Plus, the more lymph nodes that are involved, the more serious the cancer.
A procedure that is widely used is called sentinel lymph node biopsy. It is effective as a less invasive technique than conventional axillary lymph node dissection to determine if certain cancers have spread.
Sentinel nodes are a small cluster of lymph nodes to which cancer first spreads from the primary tumor. In a sentinel node biopsy, a surgeon removes only one or a few of the sentinel nodes instead of the larger number of nodes typically removed for biopsy. The surgeon identifies the sentinel nodes to remove by injecting a radioactive tracer substance or dye near the tumor. Then, using a scanner, he or she searches for the nodes containing the dye/tracer and removes them to check for cancer cells.
A study reported in a 2003 issue of the New England Journal of Medicine found that sentinel node biopsies of women with small breast cancers caused fewer side effects (such as swelling, pain and numbness) than conventional biopsy procedures and was a safe and accurate way to evaluate lymph nodes in women with small breast cancers.
Other factors that help determine treatment and prognosis include the following:
- Tumor size. In general, patients with small tumors have a better prognosis than do patients with large tumors.
- Histologic grade. This term refers to how much the tumor cells resemble normal cells when viewed under the microscope. The grading scale usually ranges from 1 to 3. Grade 1 tumors are composed of cells that closely resemble normal ones. Grade 3 tumors contain very abnormal-looking and rapidly growing cancer cells.
- Hormone receptors. Cells in the breast contain receptors for the female hormones estrogen and progesterone. These receptors allow the breast tissue to grow or change in response to changing hormone levels. Research finds that about two-thirds of all breast cancers contain significant levels of estrogen receptors. These tumors are said to be estrogen receptor positive (ER+). Tumors that contain progesterone receptors are said to be progesterone receptor positive (PR+). About two-thirds of breast tumors contain at least one of these receptors. Tumors that are hormone receptor positive are more likely to respond to hormone therapy. These tumors also tend to grow less aggressively, resulting in a better prognosis.
- Gene patterns. Looking at patterns of a number of different genes at the same time (called gene expression profiling) can help predict how likely an early stage breast cancer is to recur after initial treatment. There are two tests of gene patterns currently available: the Oncotype DX and the MammaPrint.
Other tests may be performed to check the growth rate of the cancer and to help determine appropriate therapy.
In addition, about 25 to 30 percent of women with breast cancer have an excess of a protein called HER2, which makes tumors grow quickly. Two genetically engineered drugs, trastuzumab (Herceptin) and lapatinib (Tykerb), bind to HER2 to help fight cancer cells. Trastuzumab was initially approved for treatment of metastatic breast cancer, but it has since been approved for adjuvant therapy (meaning it can be used in addition to other types of therapy, such as surgical excision or radiation) of early breast cancer. The more recently approved lapatinib is used in combination with another cancer drug called capectabine (Xeloda).
Pregnancy and Breast Cancer
Breast cancer can occur during pregnancy or within the first year after giving birth. Unfortunately, changes in the breast during pregnancy and lactation may make detection difficult. Pregnancy also limits the treatment options for breast cancer.
Surgery remains an option, however, with special care taken during anesthesia, but radiation must be delayed until after the pregnancy because of its dangerous effects on the developing fetus.
However, chemotherapy can be given in the second or third trimester. Or, for women who want to save their breasts, chemotherapy can be given before surgery and radiation delayed until after delivery.
Post-Mastectomy and Reconstruction
After a mastectomy, some women may choose to wear a prosthesis (an artificial breast form). Others may decide to have breast reconstruction.
There are several methods to rebuild the breast after mastectomy. The method must be tailored to the individual patient’s needs. The simplest operation is to place an implant behind the remaining muscle and create a mound that resembles a normal breast. In some cases, breast reconstruction may be performed immediately following a mastectomy.
If you had a great deal of tissue removed, more skin can be created with a tissue expander. This is a balloon-type device that is placed beneath the muscle and skin. Over several weeks this is made larger by almost painless injections of saline in the health care provider’s office. After several months, the expander is replaced by a permanent implant.
Another approach is flap surgery. It uses tissue from your back, thigh or abdomen to rebuild the breast. This tissue is moved into its new position, leaving a defect at the donor site. It is more major surgery. If you had radiation, which can cause significant scarring, a flap may be the best option.
The scar from breast reconstruction depends on the method used. With the flap, for example, you will have a scar at the site where the flap is removed (the donor site) and another around the flap on the breast.
You can read more on breast reconstruction.
Whichever method is used, additional surgery is needed if you want to have the nipple and areola rebuilt.
Regardless of whether you have a mastectomy alone or the added reconstructive surgery, there is a period of time after the surgeries when you can expect a certain amount of pain and limited movement. Recovery times vary depending on your surgery and overall health. Various programs are available to help you regain function; ask your health care professional for a referral to one of those programs.
There is no known way to prevent breast cancer. But there are some things you can do to reduce your risk of breast cancer.
Approved in 1998, the drug tamoxifen has been shown to slash the risk of breast cancer in high-risk women by up to 50 percent. Also, the Study of Tamoxifen and Raloxifene (STAR), compared the drug raloxifene (Evista), an FDA-approved drug for the prevention and treatment of osteoporosis in postmenopausal women, with tamoxifen. The study compared the two drugs in preventing breast cancer in postmenopausal women who were at an increased risk of developing the disease and found that raloxifene and tamoxifen are equally effective in reducing invasive breast cancer risk in the studied population of women. The study also found that women who took raloxifene had fewer uterine cancers and blood clots than the women who took tamoxifen. Raloxofine did not reduce risk of noninvasive breast tumors, however. So far, studies of raloxifene have only examined the drug’s role in breast cancer prevention, not treatment.
If you have a high risk for breast cancer, talk to your health care professional about tamoxifen, raloxifene or other similar drugs to prevent breast cancer.
Although prevention is difficult, you have a much better prognosis if you can find and treat breast cancer early. To do that, follow this advice:
- At age 40 for women at an average risk of breast cancer, begin having screening mammograms every year.
- For women at high risk of breast cancer, starting at age 30 or an age determined by your health care professional, begin having annual screening mammograms together with magnetic resonance imaging (MRI).
- To make sure you get the best possible mammogram, look for the FDA certificate, which should be prominently displayed at the facility. Facilities not meeting FDA requirements may not lawfully perform mammography.
- If you’re in your 20s and 30s and at an average risk, have your health care professional examine your breasts at least once every three years.
- Become familiar with how your breasts feel and what is “normal” for you; examine your breasts periodically and see a health care professional if you feel or see any changes that don’t go away after one menstrual cycle.
- Eat a healthy diet rich in fruits and vegetables, maintain your ideal body weight, exercise regularly and drink in moderation, if at all. A University of Washington (Seattle) study found that exercise and lack of obesity in adolescence significantly delayed the onset of breast cancer, including onset in high-risk women who carried genetic mutations for the disease.
- Engage in frequent and regular physical exercise. Some studies suggest it may reduce your breast cancer risk.
- If you’re at very high risk for breast cancer because of a strong family history of breast and ovarian cancer, an inherited breast cancer gene abnormality or previous breast cancer, talk to your health care professional about a prophylactic mastectomy.
Prophylactic mastectomy is an aggressive preventive surgery that removes both breasts before any cancer is detected. It can reduce the risk of breast cancer by approximately 90 percent, but doesn’t eliminate the risk entirely. Removing the ovaries (prophylactic oophorectomy) may also be a preventive choice for women with an inherited breast cancer gene abnormality, since the risk for ovarian cancer is also greater for these women.
Facts to Know
- An estimated 207,090 new cases of invasive breast cancer were diagnosed in 2010. Approximately 39,840 women died from breast cancer in 2010. Breast cancer is the most common type of cancer in women (besides skin cancer) and the second-leading cause of cancer death in women.
- The five-year relative survival rate for localized breast cancer has increased from 72 percent in the 1940s to about 93 percent for stage 0, 88 percent for stage I, 81 percent for stage IIA, 74 percent for IIB, 67 percent for IIIA, 41 percent for IIIB, 49 percent for IIIC and 15 percent for stage IV.
- Survival after a diagnosis of breast cancer continues to decline beyond five years. Ten-year survival and beyond is also stage-dependent, with the best survival observed in women with early stage disease.
- Well-known estrogen-related risks for developing breast cancer include early menstruation (at age 12 or younger); late menopause (after age 55); and no full-term pregnancy or first child until after age 30.
- Approximately 80 percent of biopsied breast abnormalities are noncancerous, but any breast lump must be evaluated by a physician. New, less invasive biopsy procedures permit removal of breast tissue in a physician or radiologist’s office.
- Sometimes more than one mammogram may be necessary to evaluate an abnormality. Common reasons for additional mammograms include film views that are unclear or different views requested by the radiologist.
- Some mammography centers provide immediate interpretation of your mammogram. This service can help prevent anxiety caused by waiting days to hear your results. Any additional films required also can be taken during the same visit.
- Many women panic when they see the “one in eight women will be diagnosed with breast cancer in her lifetime” statistic, but when the numbers are broken down, this means one in 233 women in her 30s will be diagnosed with breast cancer; one in 69 in her 40s; one in 36 in her 50s; and one in 27 in her 60s. The annual risk of an 85-year-old woman being diagnosed with breast cancer is 15 times that of a 30-year-old woman.
- Some breast cancer cases are the result of a mutation in the BRCA 1 or 2 genes, which can be inherited. Hereditary breast cancer makes up approximately 5 to 10 percent of all breast cancer. Women who have an altered gene related to breast cancer and who have had breast cancer in one breast have an increased risk of developing breast cancer in the other breast. These women also have an increased risk of developing ovarian cancer and may have an increased risk of developing other cancers.
- Different types of treatment are available for patients with breast cancer. Some treatments are standard, and some are being tested in clinical trials. The four types of standard treatment currently used are surgery, radiation therapy, chemotherapy and hormone therapy.
- Why is it important to find a lump or other breast abnormality early?If detected early, breast cancer can often be treated effectively with surgery that preserves the breast, followed by radiation therapy. This local therapy is often accompanied by systemic chemotherapy and/or hormonal therapy. Five-year survival after treatment for stage 0 and stage 1 breast cancers is close to 100 percent.
- I’m only 25—do I need to worry about breast cancer?Although it is rare, breast cancer can occur in women under 30. Make an effort to find out if breast cancer has occurred in any of your relatives. If so, speak to your health care professional about a plan of action. A typical plan includes periodic breast self-examinations and regular mammograms and MRIs beginning at age 30. Breast cancer incidence increases with age, rising sharply after age 40. About 80 percent of invasive breast cancer occurs in women over age 50.
- A friend told me her routine mammogram was “abnormal.” What does this mean, and what should a woman do if she receives this type of report?Along with the increased use of mammography comes a greater chance that a woman will have a result that needs more study. Any mammogram with an abnormal report is cause for additional testing to determine the nature of the abnormality. It may not necessarily be cancer, but only more testing will tell you this for sure. Additional testing can involve more mammograms and possibly a biopsy of the abnormality.
- My doctor said my mammogram was suspicious—what does that mean?Mammograms that are labeled “suspicious” or “abnormal” means there are signs that are strongly suggestive of a cancer, such as an irregular mass, contraction of the tissue around it, groups of small calcifications, underarm lymph node involvement or thickening of the skin.
- What could it be if it is not breast cancer?A frequent type of abnormality appears as calcifications, which are seen as white specks grouped in clusters or in strings on the films from your mammogram. Calcifications themselves are not cancer but may be present in the midst of a cancer. Clustered small calcifications alone are associated with an increased risk of cancer. The way these calcifications are positioned within the breast and their number and shape can provide a radiologist with a suggestion of whether these should be left alone or further examined for invasive or preinvasive disease. If your mammogram reveals a mass, one that is star-shaped or irregularly bordered is more suspicious than a round or smooth-edged mass, which is more likely to be a fluid-filled cyst.
- My doctor ordered a second mammogram, and it’s still not clear. What next?After re-imaging or a follow-up mammogram, if unresolved concerns persist, the next step is to learn more about the area in question. If a cyst is suspected, a sonogram (ultrasound) can often determine if a mass is a cyst that can be drained or is solid and requires a biopsy. Many biopsy options exist today, including image-guided core needle procedures that remove small quantities of tissue from the area in question and can be completed in a doctor’s office.
- How do I know if I’m at high risk of getting breast cancer?A woman is considered at higher risk for breast cancer if she has a mother, sister or daughter who has been diagnosed with breast cancer. About 5 to 10 percent of all breast cancer patients are believed to carry a mutation in the BRCA1 or BRCA2 gene. A carrier of BRCA1/2 may have as high as an 80 percent lifetime chance of developing breast cancer and a 60 percent risk of developing ovarian cancer.
- I have atypical hyperplasia. What does that mean?This type of noncancerous breast disease is characterized by a growth of abnormal cells within the breast ducts. Premenopausal women with a biopsy-confirmed diagnosis of atypical hyperplasia are at increased risk for later developing invasive breast cancer.
- I have large breasts and I’ve been having a strange pain in one of them. Am I at risk of having breast cancer?There is no known correlation between breast size and cancer. Also, breast pain is very commonly due to noncancerous conditions and is not usually the first symptom of breast cancer. However, you should contact your health care professional about any unusual symptoms that persist.
- I want to have breast reconstruction, but what about the horror stories about silicone implants?There are various alternatives, including saline implants or using tissue from your abdomen or from other areas of the body to reconstruct a breast. Depending on your situation, you may even be able to have breast reconstruction at the time of mastectomy. But you would likely have to return to surgery if you wanted a nipple and areola added. Nowadays, however, you can have breast reconstruction as an outpatient, depending on your health and stage of cancer.
- Coping with a breast cancer diagnosis
Don’t ever blame yourself for getting breast cancer. Scientists have identified a number of risk factors, but no one knows what causes this disease. Racking your brain for reasons is a waste of energy; there are no answers. And don’t feel pressured to carry out your “to-do” list to the degree that you did before your diagnosis. For example, forgive yourself if you are late for a lunch date or forget to send your nephew a birthday card. People will understand.
- Fatigue to be expected
If you are undergoing cancer treatment or expect to be, it’s important to plan for the eventuality that you may feel very fatigued during the treatment period. If possible, arrange in advance to have friends and family pitch in with meal preparation, child care, caring for your pets and other household tasks in case you just don’t feel up to doing such things. Speak with your employer about taking time off or working flexible hours while you’re undergoing treatments. Studies have shown that general fatigue, including fatigue caused by anemia, affects more than three-quarters of patients undergoing cancer treatment. Other side effects of treatment can include nausea, depression and pain.
- Hormone replacement therapy increases breast cancer risk
Taking combined estrogen-progestin hormone replacement therapy may increase your breast cancer risk more than taking estrogen alone, according to a study of 16,000 women in the federally funded Women’s Health Initiative (WHI). The most recent results from the study found that not only did combined hormone therapy increase the risk of breast cancer, it also increased the chance that the cancer would be found at a later stage.
- Free and low-cost mammograms available
The cost of mammography varies from state to state. Most health insurers and Medicare cover mammography, an X-ray screening for breast cancer. for referrals to free or low-cost mammography to qualifying women.
You can also e-mail the National Breast Cancer Foundation at safegenericpharmacy.com . October is National Breast Cancer Awareness Month, when many mammography facilities offer reduced fees and extended hours. If you need an October appointment, it helps to call in September to reserve a slot.