Breast cancer refers to the growth of abnormal cells in the breast. These cells are often referred to as malignant or cancerous. Cancer can develop in any area of the breast, including the:
- Lobules (glands that make milk)
- Ducts (tubes that transport milk to the nipple)
- Stroma (tissue that surrounds and supports the ducts and lobules)
The two most common areas are the ducts (ductal carcinoma) and lobules (lobular carcinoma).
When breast cancer is only present in the milk duct (i.e. has not spread to other areas of the breast) it is called noninvasive or “in situ.”
- Ductal carcinoma in situ (DCIS) is cancer that started in the milk ducts, but has not yet spread to tissues outside the duct. DCIS can progress to invasive cancer if it is not treated.
- Lobular carcinoma in situ (LCIS) is the presence of abnormal cells in the breast lobules. These abnormal cells are not cancer, but their presence increases the risk of invasive cancer developing in the future. LCIS is therefore considered a “marker” for the development of invasive cancer in either breast.
Breast cancer that has spread from its initial location in the ducts or lobules to other areas of the breast is called invasive or infiltrating. The two most common types of invasive breast cancer are infiltrating ductal carcinoma (IDC) and infiltrating lobular carcinoma (ILC).
Estrogen receptor-positive (ER-positive) and progesterone receptor-positive (PR-positive) breast cancers are sensitive to specific hormones.
- In ER-positive and PR-positive breast cancer the hormones encourage the growth of the cancers. These cancers can be treated with medications that block the effects of estrogen.
- If breast cancer is not sensitive to the female hormone estrogen, it is called estrogen receptor-negative (ER-negative).
- If breast cancer is not sensitive to progesterone, it is called progesterone receptor-negative (PR-negative).
Human Epidermal Factor Receptor 2-positive (HER2-positive) breast cancer indicates the presence of a gene that encourages the growth of breast cancer cells.
- HER2-positive breast cancer tends to grow faster, be more invasive and have an increased chance of returning.
- Three new drugs that target this gene are now available. These drugs have been quite effective in reducing the risk associated with this form of breast cancer.
Triple negative breast cancer is cancer that is negative for both of the hormone receptors (estrogen and progesterone) and human epidermal factor receptor (HER2).
- This type of breast cancer can often be more aggressive and challenging to treat than other types of breast cancer.
- The response to treatment and overall prognosis may be less favorable than cancers that are not triple negative.
In some cases, cancer cells block lymph vessels in the breast. This blockage leads to a reddened, inflamed breast.
- When this redness occurs, the condition is called inflammatory breast cancer.
- Inflammatory breast cancer also tends to be an aggressive form of breast cancer. It requires treatment with surgery, radiation and chemotherapy.
Your healthcare provider will look to see if your breast cancer has spread to other areas of your body. This process is called “staging.” In early cases of breast cancer (lumps smaller than five cm) spreading of the cancer is quite rare. Therefore, it is usually not necessary to do additional imaging studies to check for other cancers.
- Metastatic breast cancer is cancer that started in the breast and has spread to other organs.
- Typically, breast cancer first spreads to the lymph glands under the arm.
- In advanced cases, the cancer can involve the bones, lung, liver, brain and other organs.
Your healthcare provider will need the following clinical information to decide what type of treatment is right for you.
- What does the cancer look like under the microscope?
- Has the cancer spread outside the milk ducts, lymph glands under the arm or anywhere else in the body?
- How large is the primary cancer in the breast?
- Does the breast cancer have receptors for estrogen and progesterone?
- Does the cancer have large amounts of the HER2 gene?
Radiation therapy involves the use of various forms of radiation, or high-energy x-ray beams, to kill cancer cells in a specific area of the body. Radiation therapy can be used:
- Before surgery to make a tumor smaller
- After surgery to prevent a cancer from returning
- As an alternative to surgery
- To cure a cancer that cannot be removed by surgery
- To decrease symptoms that are related to a tumor or an aggressive cancer
- With chemotherapy
Radiation therapy can be given in various ways, depending on what type of cancer you have and where it is located in your body.
- Radiation therapy to treat breast cancer is usually given externally by a machine that is located outside the body. The machine sends high energy x-ray beams to the tumor.
- The x-ray beams can kill the cancer cells and shrink a tumor or even make it disappear.
- The x-ray beams must pass through normal tissue on their way to the cancer and out of the body. The radiation that passes through normal organs can cause damage.
- Radiation oncologists plan treatments to minimize exposure to normal organs.
- The treatments must be given daily over several weeks because normal tissues don't tolerate a large dosage given at one time.
Some types of radiation therapy include:
- Three-dimensional (3D) conformal radiation, which uses a beam that goes straight through the body. The patient's position is changed so this beam comes through from two or three different angles. The approach is planned to allow the maximum exposure of radiation to the tumor.
- Intensity-modulated radiation therapy (IMRT) uses hundreds of angles to accomplish the same task. It is far more expensive and is used when many angles are necessary. This approach helps to spare an important organ that is not affected by the cancer. In IMRT the intensity of the beam is varied to conform to the shape of the tumor. The aim is to limit damage to surrounding healthy tissues, while effectively treating the cancer. IMRT is a valuable technique for treating a small percentage of cancerous tumors, but adds little value in the treatment of others. IMRT may not be covered by your health plan unless certain criteria are met.
- Brachytherapy applies the radiation source right next to a tumor. Most brachytherapy for breast cancer is given at the time of surgery. Early studies suggested that this approach was as effective as external 3D conformal or IMRT and did not require the additional weeks of therapy.
- Radiation can also be given orally in the form of a pill or capsule that is swallowed. It can also be given by infusion of a radioactive substance into a vein (intravenous).
The decision to administer radiation therapy will depend on the type of surgery used for breast cancer. A lumpectomy almost always requires four to six weeks of radiation therapy to prevent recurrence of the breast cancer. Depending on the tumor, patients with modified radical mastectomies may also require radiation therapy after surgery.
There are many factors that increase your chance of getting breast cancer. These risks factors can be divided into those that you cannot control and those that you can control or eliminate. Some of the uncontrollable risks factors for breast cancer include:
- Age - You have a higher risk as you age.
- Sex - Although men can get breast cancer, women have a much higher risk.
- Family history - A close family member had cancer of the breast, uterus, ovary or colon.
- Menstrual cycle - You started your period before age twelve or went through menopause after you were fifty-five. This is thought to be due to prolonged estrogen exposure.
- Genetics - You have a defect in the BRCA1 or BRCA2 gene. These genes produce a protein that helps protect the body from cancer. Only about 1percentage of women with strong family histories of breast and ovarian cancer have this gene.
Some of the controllable risks factors for breast cancer include:
- Alcohol use - The risk increases as more alcohol is consumed.
- Childbirth - You have never had children or you had your first child after the age of thirty. Women that have more than one child may have a decreased risk of breast cancer.
- DES exposure - You were given diethylstilbestrol (DES) to prevent a miscarriage.
- Hormone therapy - You have taken estrogen replacement therapy (HRT) for many years.
- Obesity - You are obese. Some have noted that fat cells produce more estrogen, which increases the growth of certain types of breast cancer.
- Radiation - You underwent radiation treatment, especially if you received the radiation as a child or young adult.
FYI: There are no conclusive links between breast cancer and underwire bras, antiperspirant or breast implants.
Things you can do to decrease your risk of developing breast cancer, or catch it at a very early (curable) stage, include:
- Screening mammograms as recommended by your healthcare provider.
- Know how your breasts normally look and feel. Report any changes to your healthcare provider.
- Make lifestyle changes that include limiting your alcohol intake, exercising regularly, eating a healthy diet and maintaining a healthy weight.
- Discuss the pros and cons of hormone therapy after menopause, genetic testing, preventive medications and preventive surgeries with your healthcare provider.
There are frequently no symptoms in the early stages of breast cancer. This is why appropriate screening is important. Some of the symptoms that can develop as the cancer grows include:
- A lump in the breast or armpit
- A change in the appearance of the breast or nipple (redness, dimples, or puckering)
- Bloody, clear, yellow or green discharge from the nipple
As the cancer advances, more symptoms can develop. These include:
- Pain in the breast or bones
- Sores or ulcers on the skin
- Swelling under the arm next to the breast with cancer
- Unexplained weight loss can develop
Contact your healthcare provider if you have any of the symptoms noted above. He or she will perform a physical examination of your breasts, underarms, neck and chest. They may also recommend one or more of the following tests:
- Mammography to screen for and evaluate breasts lumps
- MRI of the breast to screen women at high risk or evaluate an abnormality in the breast
- Ultrasound of the breast to determine if a lump is solid or filled with fluid
- Removal of tissue for examination under a microscope (biopsy)
If you have specific symptoms, or a large cancer, your healthcare provider may also recommend:
- A CT scan
- A positron emission tomography (PET) scan
- A lymph node biopsy (to see if the cancer has spread to the lymph nodes)
The treatment for breast cancer is based on many factors. These factors include:
- Your age and if you have gone through menopause
- The type and stage of the cancer
- If the cancer is hormone sensitive
- Whether the gene called HER2 is overproduced
- Other tests that determine the specific characteristics of the cancer
Treatments for breast cancer are either local (only affects the area of the cancer) or systemic (affects all areas of the body). Local treatments include:
- Surgery to remove the cancer
- Radiation to kill the cancer cells
Systemic treatments include:
- Chemotherapy to kill the cancer cells
- Hormone therapy to block the effect of hormones that increase cancer growth
- Targeted or biologic therapy to interfere with the changes in cells that help the cancer grow
Treatment for breast cancer usually involves a combination of local and systemic treatments. You may also have more than one type of cancer treatment at a time. Depending on your situation, you may alternate between chemotherapy and radiation before or after surgery.
- Radiation and chemotherapy are usually given in a physician clinic or hospital by specially trained medical personnel.
- In some cases, you may be able to receive chemo at home with the help of specially trained nurses.
To get a full range of opinions and perspectives, you may want to consider input from a variety of doctors. This group may include:
- Your primary care physician
- A medical oncologist (a doctor who specializes in the treatment of cancer)
- A surgeon with experience in breast cancer
- A radiation oncologist (a doctor who specializes in treating cancer with radiation therapy)
- A genetic counselor
It is important to remember that the total cost of this care path does not include all possible medications, lab work, or imaging studies; those charges can add up. If your healthcare provider recommends any lab work or imaging studies, you may need to search for their costs separately.
Contact your healthcare provider if you have symptoms of breast cancer. Be prepared to discuss your symptoms and how long you've had them.
- Bring a copy of your medical history (past illnesses, surgeries, and hospitalizations).
- Make a list of your medications (including over-the-counter).
- Write down any questions, symptoms or concerns you want to talk about.
- If your healthcare provider prescribes a medication for you, ask for a generic version. If your doctor thinks that a generic version is not right for you, ask for a medication on the lowest available tier of your Prescription Drug List (PDL).
What should I ask my healthcare provider before having radiation therapy?
- How will radiation improve my prognosis?
- What specific precautions do I need to take after receiving radiation therapy?
- What are the possible complications?
- How will I feel after radiation therapy? Will I have to modify my activity?
- What type of radiation will I receive? What symptoms should I report to my healthcare provider before my next appointment?
- Is there a reason you are recommending one form of radiation therapy over another?
- Will I be receiving other treatments along with the radiation therapy?
It is important you understand all home care instructions (including medications and side effects) and follow-up plans. Don't forget to make arrangements for help at home.